Background: Ticagrelor improves survival in patients with acute coronary syndromes (ACS) compared to clopidogrel. Patients are often urgently loaded with P2Y12 inhibitors in the setting of ACS, with little time to consider barriers for continuation in the outpatient setting. We sought to evaluate the association between socioeconomic factors (type of insurance, medication co-payment) and patient choice to switch from ticagrelor to clopidogrel prior to hospital discharge.
Methods: Our medical center implemented a standardized protocol to load ACS patients with ticagrelor in 2015. During the hospitalization, pharmacists specialized in cardiovascular treatment reviewed the out-of-pocket costs with the patient and assessed their willingness to continue ticagrelor in the outpatient setting. Based on patient choice, some patients were re-loaded with clopidogrel prior to discharge. Using the ACTION Registry-GWTG, we identified all ACS patients who were loaded with ticagrelor since the start of the protocol. We examined the association between switching and socioeconomic factors using chi-squared and rank sum tests.
Results: We identified a total of 162 ACS patients who were loaded with ticagrelor prior to percutaneous coronary intervention (PCI). Of these patients, 84 (51.9%) were discharged on clopidogrel. Patients who switched to clopidogrel prior to discharge were more likely to have federal outpatient or no prescription insurance (p<0.01), and were more likely to be non-white race (p=0.05; Table). Co-payment data were available for 70.4% of the 162 ticagrelor-loaded patients. For patients who were discharged on ticagrelor, the median monthly co-payment for continuing the drug in the outpatient setting was $18.00 (interquartile range, 18 to 45). The median monthly co-payment for patients who were not discharged on ticagrelor was $253.77 (IQR, 45 to 350; p<0.01).
Conclusion: Co-payment, race, and prescription insurance are associated with patient choice to switch from ticagrelor to clopidogrel in the ACS setting. This finding implies that socioeconomic factors, namely drug cost, are barriers to implementation of standardized ticagrelor use in ACS patients. While clinical trials suggest a mortality benefit with ticagrelor, real-world practice may not realize this benefit.