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Health Insurance Rules Affect Medical Outcomes

Better results came when clot-busting drug was easily available, Canadian study shows

WEDNESDAY, Oct. 22, 2008 (HealthDay News) -- Changing the rules about prescribing a clot-preventing drug made a difference in the lives of heart patients, a new Canadian study finds.

When the Ontario health insurance system made it easier for doctors to prescribe Plavix to people who had stents implanted after artery-opening procedures, the number of deaths, heart attacks and subsequent cardiac procedures went down significantly, according to a report in the Oct. 23 issue of the New England Journal of Medicine.

"We anticipated that there would be a reduced delay in receiving the medication when a less restrictive policy was adopted," said study author Cynthia A. Jackevicius, an associate professor of pharmacy at the Western University of Health Sciences in California. "It also changed the medical outcomes."

Immediate use of Plavix (clopidogrel) is recommended along with aspirin for anyone who has a stent implanted to help keep blood flowing after an artery-opening procedure. But when Ontario rules required doctors to get approval of the drug, use of the drug was started in only 35 percent of cases in the 30 days after people left the hospital, the study found. The drug treatment was not started for nine days on average.

After the rule was relaxed, Plavix therapy was started in 88 percent of cases after hospital release, and people began taking it almost immediately.

Comparing 3,428 people treated under the old rule with 2,733 treated after the rule was changed, the researchers found a one-year reduction in the death rate, from 5 percent before to 4 percent. The rate of heart attacks decreased from 5 percent to 3 percent, and the need for bypass surgery was halved, from 2 percent to 1 percent.

Overall, the rules change reduced deaths and cardiac problems from 15 percent of those treated to 11 percent over the following year.

In the United States, Jackevicius said, "there are still a fair amount of programs that require prior approval by health insurers" for use of Plavix after stents are implanted.

"It varies extremely widely," she said. "The one that probably is most restrictive is Medicaid."

The lesson for people who have stents implanted is the importance of taking Plavix after they leave the hospital, Jackevicius said. "Therapy is started in the hospital," she said. "There can be a gap in therapy until approval comes through. Patients definitely should know that what they are taking in the hospital, they should continue to take at home, as there are potential delays."

The lesson of this study does not necessarily apply to other heart medications, said Dr. Jack V. Tu. A professor of medicine at the University of Toronto, he is also a senior scientist at the Institute for Clinical Evaluative Sciences, the Canadian equivalent of the U.S. National Institutes of Health, where he has done numerous studies of heart disease.

"For some medications, requiring prior approval is not a bad policy," Tu said. "We need to be cautious about policies that do not have an important effect on outcome. But in this type of scenario, where the guidelines recommend immediate use after angioplasty, it is not a good policy to require prior approval."

More information

Learn when and why Plavix is prescribed from the Cleveland Clinic.

SOURCES: Cynthia Jackevicius, Pharm.D, associate professor, pharmacology, Western University of Health Sciences, Pomona, Calif.; Jack V. Tu, M.D., professor, medicine, University of Toronto; Oct. 23, 2008, New England Journal of Medicine
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