Variation in initiating secondary prevention after myocardial infarction by hospitals and physicians, 1997 through
Andrea V Margulis1, Niteesh K Choudhry, Colin R Dormuth
1Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA. andreamargulis@post.harvard.edu
Insights
Secondary prevention medication initiation for myocardial infarction (MI) survivors is increasing, but significant variation exists between hospitals and physicians. This highlights a need for improved guideline adherence in post-MI care.
Area of Science:
- Cardiology
- Health Services Research
- Pharmacology
Background:
- Secondary prevention medications are crucial for myocardial infarction (MI) survivors, as recommended by clinical guidelines.
- Adherence to these guideline-recommended therapies remains suboptimal, impacting patient outcomes.
- Understanding variations in prescribing practices is essential for improving care quality.
Purpose of the Study:
- To describe the initiation rates of secondary prevention medications in MI survivors.
- To analyze the variation in initiation of these medications based on discharging hospital, physician, and the primary prescribing physician.
Main Methods:
- A cohort of 28,613 MI survivors discharged alive and without 30-day readmission was analyzed.
- Physicians responsible for prescribing were identified as those with the highest volume of cardiac medication prescriptions post-discharge.
- Multilevel logistic regression models were used to assess variations in drug initiation, adjusting for patient and provider characteristics.
Main Results:
- Initiation of beta-blockers, angiotensin-blocking agents, and statins significantly increased from 1997-2004.
- Wide variations in drug initiation probabilities were observed at both hospital and physician levels, even after adjustments.
- The greatest variation was noted for statin initiation, particularly high-potency statins, at the post-discharge prescriber level.
Conclusions:
- While the initiation of guideline-recommended secondary prevention drugs is rising among MI survivors, significant disparities persist.
- Substantial variation in prescribing practices exists between discharging hospitals and physicians.
- Addressing these variations is critical to ensure equitable and optimal secondary prevention for all MI patients.
Purpose:
Myocardial infarction (MI) survivors benefit from receiving secondary prevention, including beta-blockers, angiotensin-blocking agents, and statins, as recommended by guidelines. Compliance with these guidelines is suboptimal. We sought to describe the initiation of secondary prevention in MI survivors, and to describe the variation in initiation by discharging the hospital, the physician, and the physician "responsible" for secondary prevention prescribing decisions in British Columbia in 1997-2004.
Methods:
We assembled a cohort of 28,613 patients discharged alive from the hospital after their first MI and were not readmitted within 30 days. Physicians responsible for prescribing post-MI secondary prevention medications were identified as the physicians prescribing the greatest number of cardiac medications (post-discharge cardiac prescribers). We used multilevel logistic regression to assess the variation in drug initiation at discharging hospital, discharging physician, and post-discharge cardiac prescriber levels, which were adjusted for patient and provider characteristics during the study period.
Results:
Beta-blockers initiation increased from 56 to 71% over the 8-year study period; angiotensin-converting enzyme/angiotensin II receptor blocker initiation increased from 37 to 70%, and statin initiation increased from 22 to 66% (0-28% for high-potency statins). The probability for initiating an average patient with the study drugs varied widely in age-sex-adjusted models at the hospital and physician levels. Further adjustment did not meaningfully change findings. The variation was largest for statins. The maximum between-provider variance was found for high-potency statins in 2003-2004 at the post-discharge cardiac prescriber level.
Conclusions:
Study-drug initiation is increasing among MI survivors, but the variation in initiation is wide between discharging hospitals and physicians.
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