IMPORTANCE Despite guideline recommendations, many patients discontinue P2Y 12 inhibitor therapy earlier than the recommended 1 year after myocardial infarction (MI), and higher-potency P2Y 12 inhibitors are underutilized. Cost is frequently cited as an explanation for both of these observations. OBJECTIVE To determine whether removing co-payment barriers increases P2Y 12 inhibitor persistence and lowers risk of major adverse cardiovascular events (MACE). DESIGN, SETTING, AND PARTICIPANTS Cluster randomized clinical trial among 301 hospitals enrolling adult patients with acute MI (June 5, 2015, through September 30, 2016); patients were followed up for 1 year after discharge (final date of follow-up was October 23, 2017), with blinded adjudication of MACE; choice of P2Y 12 inhibitor was per clinician discretion. INTERVENTIONS Hospitals randomized to the intervention (n = 131 [6436 patients]) provided patients with co-payment vouchers for clopidogrel or ticagrelor for 1 year (median voucher value for a 30-day supply, $137 [25th-75th percentile, $20-$339]). Hospitals randomized to usual care (n = 156 [4565 patients]) did not provide study vouchers. MAIN OUTCOMES AND MEASURES Independent coprimary outcomes were patient-reported persistence with P2Y 12 inhibitor (defined as continued treatment without gap in use Ն30 days) and MACE (death, recurrent MI, or stroke) at 1 year among patients discharged with a prescription for clopidogrel or ticagrelor. RESULTS Among 11 001 enrolled patients (median age, 62 years; 3459 [31%] women), 10 102 patients were discharged with prescriptions for clopidogrel or ticagrelor (clopidogrel prescribed to 2317 [36.0%] in the intervention group and 2497 [54.7%] in the usual care group), 4393 of 6135 patients (72%) in the intervention group used the voucher, and follow-up data at 1 year were available for 10 802 patients (98.2%). Patient-reported persistence with P2Y 12 inhibitors at 1 year was higher in the intervention group than in the control group (unadjusted rates, 5340/6135 [87.0%] vs 3324/3967

Background Evidence‐based medication adherence rates after a myocardial infarction are low. We hypothesized that 90‐day prescriptions are underused and may lead to higher evidence‐based medication adherence compared with 30‐day fills. Methods and Results We examined patients with myocardial infarction treated with percutaneous coronary intervention between 2011 and 2015 in the National Cardiovascular Data Registry. Linking to Symphony Health pharmacy data, we described the prevalence of patients filling 30‐day versus 90‐day prescriptions of statins, β‐blockers, angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers, and P2Y 12 inhibitors after discharge. We compared 12‐month medication adherence rates by evidence‐based medication class and prescription days' supply and rates of medication switches and dosing changes. Among 353 259 patients with myocardial infarction treated with percutaneous coronary intervention, 90‐day evidence‐based medication fill rates were low: 13.0% (statins), 12.3% (β‐blockers), 14.6% (angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers), and 9.7% (P2Y 12 inhibitors). Patients filling 90‐day prescriptions were more likely older (median 69 versus 62 years) with a history of prior myocardial infarction (25.0% versus 17.9%) or percutaneous coronary intervention (30.3% versus 19.5%; P <0.01 for all) than patients filling 30‐day prescriptions. The 12‐month adherence rates were higher for patients who filled 90‐day versus 30‐day supplies: statins, 83.1% versus 75.3%; β‐blockers, 72.7% versus 62.9%; angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers, 71.1% versus 60.9%; and P2Y 12 inhibitors, 78.5% versus 66.6% ( P <0.01 for all). Medication switches and dosing changes within 12 months were infrequent for patients filling 30‐day prescriptions—14.7% and 0.3% for 30‐day P2Y 12 inhibitor fills versus 6.3% and 0.2% for 90‐day fills, respectively. Conclusions Patients who filled 90‐day prescriptions had higher adherence and infrequent medication changes within 1 year after discharge. Ninety‐day prescription strategies should be encouraged to improve post–myocardial infarction medication adherence.

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