Variations in Coronary Artery Disease Secondary Prevention Prescriptions Among Outpatient Cardiology Practices

Abstract

Objectives This study assesses practice variation of secondary prevention medication prescription among coronary artery disease (CAD) patients treated in outpatient practices participating in the NCDR® PINNACLE Registry®. Background Among patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics. Methods Using data from NCDR® PINNACLE Registry®, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics. Results Among 156,145 CAD patients in 58 practices, 103,830 (66.5%) were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% CI 1.2,1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients. Conclusions Among a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice.

Practice‐Level Variation in Outpatient Cardiac Care and Association With Outcomes

“…Several studies have demonstrated substantial variation in the medical management of specific conditions across cardiology practices 12, 13, 14. To date, no study has measured the extent of variation in the delivery of common cardiac services across cardiology practices in the outpatient setting, specific services contributing to variation, or the association between intensity and outcomes.…”

Differences Among Cardiologists in Rates of Positive Coronary Angiograms

“…An MOR of 1.0 would suggest no variation among physicians, and a greater MOR would suggest the presence of variation among individual physicians. An MOR >1.2 has been recognized as a marker of clinically significant variation 11, 12…”

2015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance Measures

“…Each of the original writing committees that developed the measures revised in this update identified secondary 12 Reports from the National Cardiovascular Data Registry PINNACLE Registry of ambulatory patients with CAD revealed that only 66 .5% (103 830 of 156 145) were receiving optimal medical therapy (OMT), including statins, 13 that 77 .8% (30 160 of 38 775) were prescribed statins, 14 and that uninsured patients were 6% less likely to receive lipid-lowering therapy . 15 Additionally, the study by Maddox and colleagues found substantial variation in prescription patterns by practice site .…”