Clopidogrel use and hospital quality in medically managed patients with non-ST-segment-elevation myocardial
Thomas M Maddox1, P Michael Ho, Thomas T Tsai
1VA Eastern Colorado Health Care System, Denver, CO, USA. thomas.maddox@va.gov
Insights
Clopidogrel is underused in non-ST-segment-elevation myocardial infarction (NSTEMI) patients, with rates varying widely by hospital. Improving hospital care quality had only a modest effect on clopidogrel prescription rates.
Area of Science:
- Cardiology
- Pharmacology
- Healthcare Quality
Background:
- Clopidogrel is recommended for non-ST-segment-elevation myocardial infarction (NSTEMI) but is historically underused.
- Contemporary prescription rates and influencing factors require evaluation, especially concerning hospital quality of care.
Purpose of the Study:
- To evaluate current clopidogrel prescription rates in NSTEMI patients.
- To identify patient and hospital factors associated with clopidogrel use.
- To assess the impact of hospital quality of myocardial infarction (MI) care on prescription rates.
Main Methods:
- Analysis of 23,186 NSTEMI patients discharged from 382 US hospitals (Oct 2009 - Mar 2011).
- Regression modeling to determine associations between clopidogrel prescription and patient/hospital factors.
- Specific focus on the relationship between hospital quality of MI care and prescription rates.
Main Results:
- Only 54.9% of eligible NSTEMI patients received clopidogrel at discharge.
- Significant hospital-level variation in prescription rates, from 22% to 97%.
- Hospital quality of MI care showed a modest association (OR 0.68) and explained 5.7% of prescription rate variation.
Conclusions:
- Clopidogrel remains significantly underused in medically managed NSTEMI patients, with substantial hospital variability.
- While hospital quality of MI care is linked to clopidogrel use, its effect is modest.
- Improving clopidogrel use necessitates strategies beyond enhancing overall hospital MI care quality.
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.
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