Sharon Glave Frazee

Trends in Use of Ezetimibe After the ENHANCE Trial, 2007 Through 2010

IMPORTANCE Results from the Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression (ENHANCE) trial, announced in January 2008, demonstrated that ezetimibe use lowered cholesterol levels but did not slow the progression of atherosclerosis. OBJECTIVE To examine the association of this announcement with national patterns of ezetimibe prescribing, including medication initiation and discontinuation, as well as predictors of use. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of a national sample of adults 18 years or older who were continuously enrolled in plans of a large US pharmacy benefit manager from 2007 to 2010. MAIN OUTCOMES AND MEASURES Lipid-lowering therapy prescription claims were categorized as ezetimibe-containing treatments or any other lipid-lowering agent. Initiation was defined as an ezetimibe claim without another in the prior 180 days; discontinuation, as an ezetimibe claim without another in the subsequent 180 days. RESULTS From 2007 to 2010, 29.1% of the 10,597,296 continuously eligible adults obtained at least 1 lipid-lowering agent prescription. Among these adults, 17.8% were prescribed ezetimibe and 95.3% another lipid-lowering agent, predominantly statins. Ezetimibe use peaked in January 2008, when 2.5% of all adults were ezetimibe users, but declined to 1.8% by December 2010. The ENHANCE trial announcement was associated with a nonsignificant 0.16% fewer monthly ezetimibe users (P = .11) but a significant 0.14% more monthly monotherapy users and 0.30% fewer users of ezetimibe concomitant with other lipid-lowering agents (both P = .01). The ENHANCE trial was also associated with 0.44% fewer monthly ezetimibe initiations (P = .002) and 10.4% more monthly ezetimibe discontinuations (P < .001), particularly of ezetimibe monotherapy for both. More than half of adults who initiated ezetimibe use did so without first being prescribed another lipid-lowering agent, both before (50%-60%) and after (60%-70%) the trial. Those aged 50 to 64 years and those living in the East South Central US Census division were both more likely to initiate and less likely to discontinue ezetimibe after the ENHANCE trial. CONCLUSIONS AND RELEVANCE After announcement of the results of the ENHANCE trial, nearly 2% of all continuously enrolled adult beneficiaries within a large US pharmacy benefit manager used ezetimibe, although ezetimibe initiations declined and discontinuations increased.

Geographic Variation in Receipt of Psychotherapy in Children Receiving Attention-Deficit/Hyperactivity Disorder Medications

Antibiotics were prescribed during 60% of pharyngitis visits for children (Table). Narrow-spectrum penicillins accounted for 61% of antibiotics prescribed. During the 14-year study period,narrow-spectrumpenicillinprescribingdecreasedfrom65% (95% CI, 57%-72%) of antibiotics in 1997 to 1998 to 52% (95% CI, 44%-60%) in 2009 to 2010 (P = .08), while macrolides increased (P < .01) (Figure). Macrolides and first-generation cephalosporins (second-line antibiotics for GAS pharyngitis) and second-/thirdgeneration cephalosporins and amoxicillin-clavulanate (not recommended)accountedfor21%and18%ofantibioticsprescribed, respectively.

Early Marketplace Enrollees Were Older And Used More Medication Than Later Enrollees; Marketplaces Pooled Risk

Little is known about the health status of the 7.3 million Americans who enrolled in insurance plans through the Marketplaces established by the Affordable Care Act in 2014. Medication use may provide an early indicator of the health needs and access to care among Marketplace enrollees. We used data from January-September 2014 on more than one million Marketplace enrollees from Express Scripts, the largest pharmacy benefit management company in the United States. We compared the characteristics and medication use between early and late Marketplace enrollees and between all Marketplace enrollees and enrollees with employer-sponsored insurance. Among Marketplace enrollees, we found that those who enrolled earlier (October 2013-February 2014) were older and used more medication than later enrollees. Marketplace enrollees, as a whole, had lower average drug spending and were less likely to use most medication classes than the employer-sponsored comparison group. However, Marketplace enrollees were more likely to use medicines for hepatitis C and particularly for HIV.

Strategies to overcome medication nonadherence.

The suggestions by Dr Zullig and colleagues1 for improving medication adherence are laudable, but we believe their list of barriers to nonadherence overlooks 2 fundamental features of human behavior, inattention and inertia, while overemphasizing the need for engagement. Human attention is both scarce and fragile, with most behaviors occurring automatically rather than being deliberate and overt.2- 4 Humans devote their attention to that which is either pleasing or pressing; thus, things that do not immediately demand attention may not receive it. Because many behaviors are important over the long-term but not immediately pressing, inattention often leads to inertia, which creates a gap between good intentions (more exercise, better diet, taking medications as prescribed) and action.