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Abstract Background China initiated a health system reform in 2009 to achieve Universal Health Coverage (UHC) by 2020. While the effectiveness of health-system reforms has been studied, equity in health-service utilization and financial burden remains underexplored. This study evaluated whether the health system reform has improved the equity in utilization and financial burden of health services among patients with hypertension in China. Methods We obtained data from four waves of the China Health and Retirement Longitudinal Study (CHARLS) conducted between 2011 and 2018. The main outcome variables were outpatient and inpatient service utilization rates and catastrophic health expenditure (CHE) for patients with hypertension. The Standardized Concentration Index (CI) was used to measure the changing equity in health service utilization and affordability. Results Outpatient service utilization was relatively equal among patients with varying socioeconomic statuses (SESs) (CI: 0.041 in 2011 and 0.064 in 2018). Inpatient service utilization inequity improved from CI 0.144 in 2011 to CI 0.066 in 2018. CHE incidence increased from 15.6% in 2011 to 24.2% in 2018. CI for CHE declined from -0.069 in 2011 to -0.012 in 2015 but increased to -0.063 in 2018. Conclusions Health insurance expansion and poverty alleviation policies promoted equity in inpatient service utilization for hypertensive patients. However, the financial burden for the poor requires further attention through reimbursement policy adjustments for outpatient services in primary care settings.

Background: Atrial fibrillation (AF) is associated with an increased risk of stroke. This study assessed treatment patterns associated with stroke prevention among patients with AF in three major cities of the People's Republic of China. Methods: A random sample of 2,862 medical charts for patients with AF at six tertiary hospitals located in Beijing, Shanghai, and Guangzhou between 2003 and 2008 were reviewed. Patient demographics, clinical characteristics, and treatment patterns were extracted from medical charts. Antithrombotic regimens included antiplatelets, anticoagulants, and a combination of both. Descriptive analyses were performed to summarize basic antithrombotic patterns. A logistic regression model examined demographic and clinical factors associated with antithrombotic treatment patterns. Results: Of the patient sample, 55% were male, the average age was 72 years (49% ⩾75 years), 15% had valvular AF, 78% had nonvalvular AF, and the remainder had unspecified AF. CHADS2 scores ⩾2 were reported for 53% of patients. Antithrombotic treatment was not received by 17% of patients during hospitalization, and 66% did not receive warfarin. Among patients with valvular or nonvalvular AF, 33%, 30%, and 20% received antiplatelet, anticoagulation, and antiplatelet plus anticoagulation treatments, respectively. For patients with CHADS2 scores of 0, 1, 2, 3, and ⩾4, 52%, 42%, 28%, 21%, and 21%, respectively, were treated with warfarin. Predictors of no antithrombotic treatment included age and hospital location. Conclusion: Anticoagulation therapy was underused in Chinese patients with AF. Antithrombotic treatment was not associated with stroke risk. Further studies need to examine the clinical consequences of various antithrombotic treatment patterns in Chinese patients with AF. [ABSTRACT FROM AUTHOR]

ABSTRACTBackground:The study objective was to compare dose-equivalence, adherence and subsequent switch rates among patients recently switched from a branded to generic version of the samestatin (generic substitution, GS) vs. those switched from branded statin to generic version of a different statin (therapeutic substitution, TS).Methods:In a retrospective cohort analysis among adult enrollees in over 90 US health plans, the authors identified adult patients who switched from a branded to generic statin from July–December 2006 (simvastatin became generic in June 2006). Patients were classified by type of statin switch: GS (e.g., branded simvastatin → generic simvastatin), and TS (e.g., branded atorvastatin → generic simvastatin). Demographic and clinical data were collected from claims before switch through 6 months follow-up. Separate outcomes of interest included proportion of patients that switched to a less potent daily dose, that switched back to previous branded statin after switch, and that were at least 80 adherent during the 6 months after initial switch. Significant predictors of each clinical outcome were identified using multivariable logistic regression models, adjusting for differences between groups in covariates and potential confounders.Results:The 6-month TS (n  3807) and GS (n  40,165) groups were generally similar demographically. Compared to GS, TS patients were significantly more likely to be switched to a less potent dose (26.2 vs. 0.5, adjusted odds ratio [AOR] in patients with high-potency index medication  83.4, p < 0.0001); 33 less likely to be adherent in the 6 months after switch (67.7 vs. 75.9, AOR in patients with no switch in first 6 months follow-up 0.67, p < 0.0001); and four times more likely to switch back to previous branded statin (11.3 vs. 2.9, AOR 4.1, p < 0.0001).Limitations:This study did not account for co-payment changes, lipid measurements, or changes in pill burden.Conclusions:While this study did not have data on why patients had TS (e.g., for cost or clinical reasons), TS was more likely to involve a subsequent disruption to statin therapy than GS. TS could potentially lead to adverse impacts on patients’ outcomes, and should be studied further. [ABSTRACT FROM AUTHOR]

Background: In clinical practice, persistence with statin therapy is poor. While little is known about relative persistence to specific statins, previous studies have observed greater persistence in patients who achieve greater degrees of lipid lowering. Identification of statin therapies which improve patient persistence has the potential to improve the quality of patient care and clinical outcomes. Therefore, we assessed patient persistence with atorvastatin and simvastatin in primary and secondary prevention patients enrolled in managed care.Methods: New statin users aged ≥18 years, both with and without prior cardiovascular (CV) events within the 12 month pre-treatment period, were identified from a large national database of managed care patients. Patients initiated atorvastatin or simvastatin therapy from January 1, 2003 to September 30, 2005 and were continuously enrolled in a covered plan for at least 12 months before and after initiation of statin therapy. Subanalyses of patients ≥65 years were also conducted. Measures of interest included demographic and clinical characteristics of the study samples and persistence of statin utilization over the 1-year follow-up period. Persistence was defined as the number of days a patient remained on treatment in the first year following their index date, measured from the date of first fill to study end or the date of discontinuation.Results: A total of 129 764 atorvastatin users and 45 558 simvastatin users without prior CV events were included in the study. For those patients with prior CV events, a total of 6888 atorvastatin users and 4443 simvastatin users were included in the study. Median persistence in patients without prior CV events was 50 days longer for patients initiating therapy with atorvastatin than simvastatin (207 vs. 157 days, p<0.0001) and after adjusting for confounding factors, those treated with atorvastatin were 15% less likely to discontinue therapy during the first year than those treated with simvastatin (HR=0.85; 95% CI 0.84, 0.86; p<0.001). In secondary prevention patients median persistence was 85 days longer in atorvastatin patients than simvastatin patients (266 vs. 181 days, p<0.0001) and atorvastatin patients were 22% less likely to discontinue therapy (HR=0.78; 95% CI 0.75, 0.82; p<0.001). Persistence was worse in the elderly patients, but the relative difference between atorvastatin and simvastatin was similar to the overall patient population.Conclusions: In patients with and without prior CV disease, persistence is generally poor, even worse in the elderly, but significantly better for atorvastatin patients than simvastatin patients (p<0.001). Further studies are required to determine whether this is due to differences in cost, effectiveness, side-effects, or other attributes of the statins.Study limitations: Differences in persistence could be, in part, due to unmeasured confounders although all available variables were adjusted in multivariate analyses. Additionally, the claims database lacks some clinical data such as lipid levels, limiting assessments of statin efficacy, and does not include any reasons for discontinuation of therapy. [ABSTRACT FROM AUTHOR]

Objective: The clinical literature suggests that atorvastatin therapy achieves a reduction in major cardiovascular events within the first year of therapy. Aside from obvious clinical benefits, economic advantage may also result from this observation. The present analysis modeled the clinical and economic consequences of initiating atorvastatin versus generic simvastatin in defined US managed care organization patient populations.Research design and methods: A cost-consequence model was developed to estimate the differential rate and associated costs of cardiovascular events occurring over 2 years using real world price and adherence data. Four defined patient populations were included from representative atorvastatin trials: (1) diabetes mellitus; (2) multiple risk factors; (3) coronary heart disease; and (4) acute coronary syndrome. Costs of care included drug costs and costs of managing cardiovascular events. Univariate sensitivity analyses and multivariate sensitivity analysis via Monte Carlo simulation were conducted to test the robustness of the results.Main outcome measures: The number of cardiovascular events avoided per 100 000 patients initiated on atorvastatin as compared with simvastatin, and total treatment costs.Results: The model predicts that, relative to simvastatin, atorvastatin will prevent 941 (95% confidence interval [CI] 481–1367) cardiovascular events after 1 year and 1426 (95% CI 833–1987) events after 2 years, per 100 000 patients. This is expected to reduce the cost of cardiovascular events by $365 (95% CI $192–$527) and $552 (95% CI $327–$763) per patient (US$ 2006), respectively, offsetting 80% and 75% of the medication cost difference between atorvastatin and simvastatin after 1 and 2 years, respectively. The incremental costs associated with atorvastatin treatment were estimated at $94 (95% CI −$68 to $267) and $175 (95% CI −$37 to $399) per patient after 1 and 2 years, respectively. Results were sensitive to assumptions regarding simvastatin efficacy and drug acquisition costs.Conclusions: Although the present analysis is based in part on indirect comparisons and on trials not designed or statistically powered to specifically test the early benefits hypothesis, it suggests that atorvastatin''s assumed early reduction of cardiovascular events partly offsets the acquisition price difference between atorvastatin and generic simvastatin in various groups of high-risk patients newly initiated on statin treatment. [ABSTRACT FROM AUTHOR]