Care transitions from the hospital to home remain a vulnerable time for many patients, especially for those with heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Despite regular use in chronic disease management, it remains unclear how technology can best support patients during their transition from the hospital. We sought to evaluate the impact of a technology-supported care transition support program on hospitalizations, days out of the community and mortality. Using a pragmatic randomized trial, we enrolled patients (511 enrolled, 478 analyzed) hospitalized with CHF/COPD to "E-Coach," an intervention with conditionspecific customization and in-hospital and postdischarge support by a care transition nurse (CTN), interactive voice response post-discharge calls, and CTN follow-up versus usual post-discharge care (UC). The primary outcome was 30-day rehospitalization. Secondary outcomes included (1) rehospitalization and death and (2) days in the hospital and out of the community. ECoach and UC groups were similar at baseline except for gender imbalance (p = 0.02). After adjustment for gender, our primary outcome, 30-day rehospitalization rates did not differ between the E-Coach and UC groups (15.0 vs. 16.3 %, adjusted hazard ratio [95 % confidence interval]: 0.94 [0.60, 1.49]). However, in the COPD subgroup, ECoach was associated with significantly fewer days in the hospital (0.5 vs.

IMPORTANCE Although PCSK9 inhibitors (PCSK9i) were approved in 2015, their high cost has led to strict prior authorization practices and high copays, and use of PSCK9i in clinical practice has been low. OBJECTIVE To evaluate patient access to PCSK9i among those prescribed therapy. DESIGN, SETTING, AND PARTICIPANTS Using pharmacy transaction data, we evaluated 45,029 patients newly prescribed PCSK9i in the United States between 08/01/2015 and 07/31/2016. MAIN OUTCOMES AND MEASURES Main outcomes were: the proportion of PCSK9i prescriptions approved and abandoned (approved but unfilled); multivariable analyses examined factors associated with approval/abandomnent including payor, prescriber specialty, pharmacy benefit manager (PBM), out-of-pocket cost (copay), clinical diagnoses, lipid lowering medication use, and low density lipoprotein cholesterol (LDL-C) levels. RESULTS Of patients given an incident PCSK9i prescription, 20.8% received approval on the first day, and 47.2% ever received approval. Of those approved, 65.3% filled the prescription, resulting in 30.9% of those prescribed PCSK9i ever receiving therapy. After adjustment, patients who were older, male and had ASCVD were more likely to be approved, but approval rates did not vary by patient low density lipoprotein (LDL-C) level nor statin use. Other factors associated with drug approval included: having government versus commercial insurance (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.8–3.8), and those filled at a specialty versus retail pharmacy (OR 1.96, 95% CI 1.66–2.33). Approval rates varied nearly 3-fold among the top 10 largest PBMs. Prescription abandonment by patients was most associated with copay costs (c-statistic 0.86); with abandonment rates ranging from 7.5% for those with $0 copay, to more than 75% for copays greater than $350. Limitations include that the analysis was conducted in the first year of availability before outcomes trials results. CONCLUSIONS AND RELEVANCE In the first year of availability, only half of patients prescribed a PCSK9 received approval, and one third of approved prescriptions were never filled due to copay.

Many patients filling high-intensity statins following a myocardial infarction do not continue taking this medication with high adherence for 2 years postdischarge. Interventions are needed to increase high-intensity statin use and adherence after myocardial infarction.

Several randomized controlled trials have shown a benefit of high-dose intensive statin treatment in reducing risk of death and second cardiovascular disease (CVD) events in patients previously diagnosed with an acute coronary syndrome (ACS). Non-randomized studies in clinical settings support these findings, but large, long-term, observational studies addressing CVD and non-CVD endpoints are lacking. In this retrospective longitudinal study, we followed ACS patients in Sweden during 2001–2012 using national health registry and medical record data. A total of 49,857 patients were identified, of whom 10,092 (20.2%) received high dose statins and 21,174 (42.7%) received no statins. Royston-Parmar parametric time-to-event models were implemented to model hazard for second CVD events and death, stratified by gender and diabetes diagnosis. We found that risk of a second CVD event developed similarly in both treatment groups, but was much higher in the no statin group. Risk of CVD-related death remained relatively constant for the high-statin group, while it increased over time for the no-statin group. Interestingly, males had higher mortality rates in the no-statin group, but not in the high-statin group. All-cause mortality and non-CVD-related death followed similar trends to those observed for CVD-related death. This work provides additional real-world evidence for effect of statins in CVD-related mortality. The hazard functions presented here can provide a basis for future survival modeling and health economic evaluation.

A 9-point risk assessment (IVAT) identified persons with a history of injection drug use (IDU) safe for discharge. "Low risk" patients were discharged with outpatient antibiotics; others continued inpatient treatment. IVAT reduced ALOS by 20 days and total direct cost by 33%, creating capacity for an additional 333 patients.