Changes in Cardiovascular Care and Outcomes in Eight Years after Medicare Part D

心血管疾病（CVD）影响大约77%的老年人，社区居住的医疗保险人口，是这一群体住院，死亡和医疗费用的最大驱动力。自2006年以来，补贴的D部分药物福利改善了医疗保险人群所需药物的可及性，但对心血管疾病患者的具体影响尚不清楚，特别是在药物依从性，使用卫生服务和患者结果方面。此外，在D部分实施后的八年中，对老年心血管疾病医疗保险参保者的这些结果的主要趋势一无所知。使用强有力的准实验方法和具有全国代表性的医疗保险当前受益人调查（2000-2013），我们将确定14年期间患有心血管疾病的老年医疗保险患者人群，并评估D部分后他们的利用率和临床结局的即时和长期变化。研究指标将包括人口统计学和临床属性、药物和非药物利用、与成本相关的药物治疗不依从性、急性医院事件和感知健康状况。在D部分实施后的一段时间内，我们将制定和研究新的措施，包括病人成本应对策略，每月坚持和计划外购买。对于高风险心血管疾病患者（药物支出接近或高于D部分“甜甜圈洞”覆盖范围缺口阈值的患者），我们将估计2011年品牌药物覆盖范围在该覆盖范围缺口内突然改善后的结局变化。特别是，我们将按照治疗药物类别和品牌与仿制药状态，检查处于或接近覆盖缺口的D部分患者的依从性和CVD治疗强度的变化。 公共卫生相关性：医疗保险D部分的实施对获得药物和医疗服务和结果的变化的影响，对于大量患有心血管疾病的老年人来说，人们知之甚少。我们的研究旨在调查D部分实施后8年内这些重要结局的变化，特别是在2011年品牌药物大幅折扣后进入“甜甜圈洞”覆盖范围缺口的患者。

DESCRIPTION (provided by applicant): Cardiovascular disease (CVD) affects approximately 77% of the elderly, community-dwelling Medicare population and is the largest driver of hospital admissions, deaths, and health expenditures in this group. Since 2006, the subsidized Part D drug benefit has improved the accessibility of needed medications for people in Medicare, but the specific effects on those with CVD are not well-known, in particular in terms of medication adherence, use of health services, and patient outcomes. Moreover, nothing is known about major trends in these outcomes among elderly Medicare enrollees with CVD in the eight years following Part D implementation. Using strong quasi-experimental methods and the nationally-representative Medicare Current Beneficiary Survey (2000-2013), we will identify the population of elderly Medicare patients with CVD during a 14-year period and evaluate immediate and longer-term changes in their utilization and clinical outcomes following Part D. Study measures will include demographic and clinical attributes, drug and non-drug utilization, cost-related medication nonadherence, acute hospital events, and perceived health status. For the period after Part D implementation, we will develop and examine new measures including patient cost-coping strategies, month-to-month adherence, and out-of-plan purchasing. For high-risk CVD patients (those with drug spending near or above the Part D "donut hole" coverage gap threshold), we will estimate changes in outcomes following the sudden 2011 improvement in brand name drug coverage within this coverage gap. In particular, we will examine changes in adherence and CVD treatment intensity for Part D patients in or near the coverage gap, by therapeutic drug class and by brand versus generic status. PUBLIC HEALTH RELEVANCE: The effects of Medicare Part D implementation on access to medicines and changes in health services and outcomes are poorly understood for the large population of elderly with cardiovascular disease. Our study aims to investigate changes in these important outcomes in the 8 years following Part D implementation, in particular after a large 2011 discount on branded medicines for patients entering the "donut hole" coverage gap.