Prescription Abandonment and Treatment Patterns Among Formulary Designations for Chronic Heart Failure Treatment

In one of the medal-winning posters presented at AMCP 2022, lead author, Chi-Chang Chen, PhD, explained that sacubitril and valsartan (SAC/VAL) is the preferred renin-angiotensin-aldosterone system inhibitor (RAASi) for adult patients with congestive heart failure (CHF). However, the study’s collaborators noted that uptake of SAC/VAL has been slow, “partially due to access barriers.” Chen and colleagues examined the abandonment and rejection of new SAC/VAL prescriptions (Rx) among national commercial and Medicare plan members and found that over a quarter of patients failed to receive SAC/VAL at their first attempt, which led to a subsequent delay or disruption in CHF treatment.

The retrospective study included a total of 205,040 patients from the IQVIA Longitudinal Access and Adjudication Data. Across the cohort, patients were enrolled in 12 commercial and nine Medicare national plans. The primary endpoints in the study were the proportion of patients with an abandoned or rejected SAC/VAL Rx and the average delay in treatment initiation in those who later received SAC/VAL, as well as the proportion of patients who had a RAASi treatment gap of 90 days or more.

Among the cohort, 129,599 (63.2%) patients had Medicare plans and 75,441 (36.8%) had commercial plans. Over 12 months of follow-up, the most common formulary design was preferred without prior authorization (n = 125,706; 61.3%), followed by preferred with prior authorization (n = 59,288; 28.9%), non-preferred with prior authorization (n = 19,883; 9.7%), and non-preferred without prior authorization (n = 163; 0.1%). The overall rate of SAC/VAL Rx abandonment or rejection was 28.6%, with a higher rate among commercial patients compared to Medicare patients (33.4% vs. 25.9%). The highest rates were observed among patients with non-preferred formulary designs who were with or without prior authorization at 42.0% and 41.7%, respectively. The rate in patients who received a preferred formulary was 36.6% for those with prior authorization and 22.8% in those without prior authorization.

Of the 46,791 abandoned or rejected patients, only 44% (n = 20,781) had future SAC/VAL Rx approval, and those patients experienced a mean delay to treatment initiation of 96.7 days (standard deviation [SD], 82.9). Comparatively, 56.8% of the 12,626 patients who were naïve to RAASi therapy before indexing later started RAASi, and had a mean time to first RAASi of 88.7 days (SD, 87.5). Lastly, among the 20,897 patients with pre-index RAASi use, 8.3% (n = 1,736) experienced a treatment disruption.

The authors thus concluded their study showed that a significant proportion of patients “were unable to receive SAC/VAL treatment at first attempt,” which “resulted in disruption/delay in receiving CHF treatment.” In closing their article, they called for further research to examine the effects of “SAC/VAL Rx abandonment/rejection on downstream clinical and economic outcomes.”