Comparative cost-effectiveness of interventions to improve medication adherence after myocardial infarction

Abstract

Objective: To evaluate the comparative cost-effectiveness of interventions to improve adherence to evidence-based medications among postmyocardial infarction (MI) patients.

Data sources/study setting: Cost-effectiveness analysis.

Study design: We developed a Markov model simulating a hypothetical cohort of 65-year-old post-MI patients who were prescribed secondary prevention medications. We evaluated mailed education, disease management, polypill use, and combinations of these interventions. The analysis was performed from a societal perspective over a lifetime horizon. The main outcome was an incremental cost-effectiveness ratio (ICER) as measured by cost per quality-adjusted life year (QALY) gained.

Data collection/extraction methods: Model inputs were extracted from published literature.

Principal findings: Compared with usual care, only mailed education had both improved health outcomes and reduced spending. Mailed education plus disease management, disease management, polypill use, polypill use plus mailed education, and polypill use plus disease management cost were $74,600, $69,200, $133,000, $113,000, and $142,900 per QALY gained, respectively. In an incremental analysis, only mailed education had an ICER of less than $100,000 per QALY and was therefore the optimal strategy. Polypill use, particularly when combined with mailed education, could be cost effective, and potentially cost saving if its price decreased to less than $100 per month.

Conclusions: Mailed education and a polypill, once available, may be the cost-saving strategies for improving post-MI medication adherence.

Figure 1

Markov Model Structure Note. At the decision node patients were assigned to one of the seven adherent interventions. Proportions of patients adherent to different numbers of drug components of combination pharmacotherapy were determined as shown in Appendix Table 1. Then patients entered the model with the post-myocardial infarction (MI) state. Every 3 months, patients were at risk for recurrent MI, stroke, or hospitalization for congestive heart failure (CHF) with the potential of dying of these conditions. Throughout the patients' lifetime, all patients were at risk for death from causes unrelated to MI, stroke, or CHF.

Figure 2

Multiway Sensitivity Analyses of the Relative Increases in Adherence and Annual Costs Associated with Mailed Education and Disease Management Note. The figures show regions of optimal strategy under the assumption that maximum cost per quality-adjusted life year (QALY) of $100,000 is acceptable. D, disease management; M, mailed education.

Figure 3

Multiway Sensitivity Analyses of the Price of the Polypill, the Relative Increase in Adherence from Polypill Use, and Relative Effectiveness of the Polypill Compared with those of Its Components Administered Separately Note. The figures show regions of optimal strategy under the assumption that maximum cost per quality-adjusted life year (QALY) of $100,000 is acceptable.