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15-11-2011 | Cardiology | Article

Eliminating copayments for post-MI treatment improves outcomes


Free abstract

MedWire News: Results of the MI FREEE trial suggest that providing post-myocardial infarction (MI) patients with free preventive medications improves medication adherence and rates of first major vascular events, and decreases patient spending without increasing overall health costs.

"Adherence to medications that are prescribed after MI is poor," explained lead author Niteesh Choudhry (Brigham and Women's Hospital, Boston, Massachusetts, USA) at the American Heart Association Scientific Sessions 2011 in Orlando, Florida, USA. "Drug costs appear to be a central reason for medication underuse," he added.

The team evaluated the impact of eliminating copayments for statins, beta blockers, and ACE inhibitors or angiotensin receptor blockers on rates of major vascular events in post-MI patients, and the subsequent effect on health expenditure.

The MI FREEE (Post-Myocardial Infarction Free Rx Event and Economic Evaluation) trial included nearly 6000 post-MI patients who were randomly assigned to receive either full coverage, where their insurance-plan sponsors covered their full prescription costs (2845 patients, 1494 plan sponsors), or usual prescription coverage (3010 patients, 1486 plan sponsors). At enrolment, all participants were told of the importance of taking their prescribed medication, and those in the intervention group were informed of their benefit change.

The primary study outcome was first major vascular event (fatal or nonfatal acute MI, unstable angina, stroke, congestive heart failure) or revascularization. Secondary outcomes were rates of medication adherence, total major vascular events or revascularizations, the first major vascular event, and health expenditures.

Presenting the results, which also appear in the New England Journal of Medicine, Choudhry reported that adherence rates were 4-6% higher in the full-coverage group compared with the usual-coverage group (p<0.001).

No significant between-group difference was observed for the primary outcome, with rates of 17.6 and 18.8 events per 100 person-years for the full-coverage and usual coverage groups, respectively (HR=0.93, p=0.21).

However, the rates of total major vascular events or revascularization (per 100 person-years) were significantly reduced in the full-coverage group, at 21.5 versus 23.3 (hazard ratio [HR]=0.89, p=0.03).

Similarly, the rate of first major vascular event was 14% lower in the full-coverage group compared with usual coverage (11.0 vs 12.8 events per 100 person years; HR=0.86, p=0.03).

Of note, elimination of copayments did not increase total spending (US$ 66,008 [€ 48,457] for the full coverage group and US$ 71,778 [€ 52,708] for the usual-coverage group; relative spending=0.89, p=0.68). But, total patient health and cardiovascular spending was reduced by 26% and 40% with elimination of copayments, respectively (p<0.001).

"We believe this study may have many implications and could contribute to ongoing efforts to improve post-MI outcomes," commented Choudhry. "The results as they are presented appear cost-effective and it is a rarity for an intervention to actually improve patient affordability."

Moreover, he added, "the intervention we evaluated was easy and scalable, and could be started as early as tomorrow by insurers who chose to do so."

Discussant Eric Peterson (Duke University School of Medicine, Durham, North Carolina, USA) remarked: "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, he said, "widespread adoption is recommended."

He added that the trial "also highlights the huge challenges for post-MI secondary prevention, even when medications are given [for] free."

MedWire ( is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

By Nikki Withers

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