Clopidogrel Use and Hospital Quality in Medically Managed Patients With Non–ST-Segment–Elevation Myocardial Infarction

Abstract

Background— Clopidogrel prescription is a class I guideline recommendation for medically managed patients with non–ST-segment–elevation myocardial infarction (NSTEMI). However, clopidogrel has historically been underused in this population. We evaluated contemporary rates of its use and evaluated associated factors, with a particular focus on hospital quality of myocardial infarction (MI) care. Methods and Results— We examined clopidogrel prescription rates among 23 186 patients with NSTEMI discharged from 382 US hospitals between October 2009 and March 2011. Associations between clopidogrel prescription and various patient and hospital factors, including hospital quality of MI care, were determined with regression modeling. Of the sample, 54.9% of eligible patients with NSTEMI received clopidogrel prescription at hospital discharge. Variation in rate by hospital was large, ranging from 22% to 97%. A variety of patient and hospital factors were associated with clopidogrel prescription. Hospital quality of MI care demonstrated modest association with clopidogrel prescription (odds ratio, 0.68; 95% CI, 0.54–0.85) between the lowest and highest hospital quality quartile) and accounted for 5.7% of the variation in prescription rates. Conclusions— Clopidogrel prescription is significantly underused in the medically managed NSTEMI population and demonstrates wide variability by hospital. Although hospital quality of MI care is associated with its use, the findings suggest that it only has a modest effect. Therefore, efforts to improve clopidogrel use likely will require measures beyond improving the overall hospital quality of MI care.

Hospital Variation in Premature Clopidogrel Discontinuation After Drug‐Eluting Stent Placement in the Veterans Affairs (VA) Healthcare System

“…However, understanding that this variation in premature discontinuation exists is an important initial step to further evaluate the causes of the variation in subsequent research. This finding differs from previous studies that demonstrated associations between hospital characteristics and guideline‐recommended inplantable cardioverter‐defibrillator utilization14 and clopidogrel prescription at discharge for medically managed NSTEMI patients 9. These outcomes are largely dictated by provider behaviour, while premature clopidogrel discontinuation is influenced by both patients and providers.…”

“…Variability in prescription drug spending,6 cardiac procedures such as implantable cardioverter‐defibrillator implantation,7, 8 and provider adherence to established practice guidelines9 have been demonstrated. A prior study from our group showed significant national hospital‐level variation ranging from 22% to 97% in clopidogrel use for medically managed non–ST‐segment elevation myocardial infarction (NSTEMI) patients at hospital discharge 9. It is unknown whether similar variations occur in premature clopidogrel discontinuation in an integrated health care system such as the Veterans Affairs (VA) where all patients have prescription drug coverage and where copayments are low.…”

Optimal secondary prevention medication use in acute myocardial infarction patients with nonobstructive coronary artery disease is modified by management strategy: insights from the TRIUMPH Registry

“…5 Accordingly, current AMI guidelines since 2002 call for the use of dual antiplatelet therapy with P2Y12 inhibitors and aspirin in all patients with AMI for a minimum of 12 months, irrespective of CAD obstruction or receipt of PCI. 19 Similar gaps in P2Y12 inhibitor use in medically managed AMI patients have been seen in other populations, 20 and our current findings in the TRIUMPH registry further underscore the need for improvement.…”

Outcomes According to Cardiac Catheterization Referral and Clopidogrel Use Among Medicare Patients With Non–ST‐Segment Elevation Myocardial Infarction Discharged Without In‐hospital Revascularization

“…Therefore, guidelines recommend 12 months of clopidogrel treatment for NSTEMI patients, including those who did not undergo coronary revascularization . Yet prior data have shown that only half of medically managed NSTEMI patients receive clopidogrel at discharge . Whether CURE data apply to a more contemporary NSTEMI population with higher rates of evidence‐based secondary prevention use is unknown.…”

“…1 Yet prior data have shown that only half of medically managed NSTEMI patients receive clopidogrel at discharge. 4,5 Whether CURE data apply to a more contemporary NSTEMI population with higher rates of evidence-based secondary prevention use is unknown. Among older MI patients, the perceived increased risk of bleeding may reduce provider willingness to consider clopidogrel use.…”