title: Improving Adherence to Cardiovascular Therapies: An Economic Evaluation of a Randomized Pragmatic Trial.
abstract: OBJECTIVE
  Preplanned economic analysis of a pragmatic trial using electronic-medical-record-linked interactive voice recognition (IVR) reminders for enhancing adherence to cardiovascular medications (i.e., statins, angiotensin-converting enzyme inhibitors [ACEIs], and angiotensin receptor blockers [ARBs]).
  
  
  METHODS
  Three groups, usual care (UC), IVR, and IVR plus educational materials (IVR+), with 21,752 suboptimally adherent patients underwent follow-up for 9.6 months on average. Costs to implement and deliver the intervention (from a payer perspective) were tracked during the trial. Medical care costs and outcomes were ascertained using electronic medical records.
  
  
  RESULTS
  Per-patient intervention costs ranged from $9 to $17 for IVR and from $36 to $47 for IVR+. For ACEI/ARB, the incremental cost-effectiveness ratio for each percent adherence increase was about 3 times higher with IVR+ than with IVR ($6 and $16 for IVR and IVR+, respectively). For statins, the incremental cost-effectiveness ratio for each percent adherence increase was about 7 times higher with IVR+ than with IVR ($6 and $43 for IVR and IVR+, respectively). Considering potential cost offsets from reduced cardiovascular events, the probability of breakeven was the highest for UC, but the IVR-based interventions had a higher probability of breakeven for subgroups with a baseline low-density lipoprotein (LDL) level of more than 100 mg/dl and those with two or more calls.
  
  
  CONCLUSIONS
  We found that the use of an automated voice messaging system to promote adherence to ACEIs/ARBs and statins may be cost-effective, depending on a decision maker's willingness to pay for unit increase in adherence. When considering changes in LDL level and downstream medical care offsets, UC is the optimal strategy for the general population. However, IVR-based interventions may be the optimal choice for those with elevated LDL values at baseline.
authors.affiliation: Kaiser Permanente Northwest, Portland, OR, USA. Electronic address: David.H.Smith@kpchr.org.
authors.forename: David H
authors.initials: DH
authors.lastname: Smith
authors.affiliation: Kaiser Permanente Northwest, Portland, OR, USA.
authors.forename: Maureen
authors.initials: M
authors.lastname: O'Keeffe-Rosetti
authors.affiliation: Kaiser Permanente Georgia, Atlanta, GA, USA; School of Public Health, Georgia State University, Atlanta, GA.
authors.forename: Ashli A
authors.initials: AA
authors.lastname: Owen-Smith
authors.affiliation: Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Rand
authors.affiliation: Kaiser Permanente Hawaii, Honolulu, HI, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Tom
authors.affiliation: Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
authors.forename: Suma
authors.initials: S
authors.lastname: Vupputuri
authors.affiliation: Kaiser Permanente Northwest, Portland, OR, USA.
authors.forename: Reesa
authors.initials: R
authors.lastname: Laws
authors.affiliation: Kaiser Permanente Northwest, Portland, OR, USA.
authors.forename: Amy
authors.initials: A
authors.lastname: Waterbury
authors.affiliation: Kaiser Permanente Georgia, Atlanta, GA, USA.
authors.forename: Dana D
authors.initials: DD
authors.lastname: Hankerson-Dyson
authors.affiliation: Kaiser Permanente Hawaii, Honolulu, HI, USA.
authors.forename: Cyndee
authors.initials: C
authors.lastname: Yonehara
authors.affiliation: Center for Outcomes Research & Evaluation, Maine Medical Center Research Institute, Portland, ME, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Williams
authors.affiliation: Kaiser Permanente Northwest, Portland, OR, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Schneider
authors.affiliation: Kaiser Permanente Northwest, Portland, OR, USA.
authors.forename: John F
authors.initials: JF
authors.lastname: Dickerson
authors.affiliation: Kaiser Permanente Northwest, Portland, OR, USA.
authors.forename: William M
authors.initials: WM
authors.lastname: Vollmer
mesh_terms: D000368:Aged; D047228:Angiotensin II Type 1 Receptor Blockers / Q000191:economics / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics / Q000627:therapeutic use; D015415:Biomarkers / Q000097:blood; D002317:Cardiovascular Agents / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics*; D003362:Cost-Benefit Analysis; D016527:Drug Costs; D057286:Electronic Health Records / Q000191:economics; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000191:economics / Q000627:therapeutic use; D008077:Lipoproteins, LDL / Q000097:blood; D008297:Male; D008498:Medical Record Linkage; D055118:Medication Adherence; D008875:Middle Aged; D018803:Models, Economic; D010353:Patient Education as Topic / Q000191:economics*; D017010:Reminder Systems / Q000191:economics*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D015415:Biomarkers; D002317:Cardiovascular Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D008077:Lipoproteins, LDL
keywords: adherence; cardiovascular; diabetes; economics