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Variability of antithrombotic dosing among veterans presenting with acute coronary syndrome

Mary E Plomondon1, Anne C Lambert-Kerzner1, Xuefei Jennewein2

  • 1VA Eastern Colorado Health Care System, Denver, CO (M.E.P., A.C.L.K., K.F., M.M.C., K.B.F., T.T.T., M.H.) University of Colorado School of Medicine, Denver, CO (M.E.P., A.C.L.K., T.T.T., M.H.).

Journal of the American Heart Association
|April 29, 2015
PubMed

Insights

Dosing of unfractionated heparin (UH) and low-molecular-weight heparin (LMWH) for acute coronary syndrome (ACS) patients varied widely across hospitals. This variability highlights the need for improved provider training and adherence to dosing guidelines to ensure patient safety and treatment effectiveness.

Area of Science:

  • Cardiology
  • Pharmacology
  • Health Services Research

Background:

  • Clinical practice guidelines recommend antithrombotic therapy for acute coronary syndrome (ACS) patients.
  • Appropriate antithrombotic dosing is crucial for effectiveness and safety, and is an ACC/AHA performance measure.
  • Variability in unfractionated heparin (UH) and low-molecular-weight heparin (LMWH) dosing was assessed in an integrated healthcare system.

Purpose of the Study:

  • To describe the variability in the dosing of unfractionated heparin (UH) and low-molecular-weight heparin (LMWH) among patients with acute coronary syndrome (ACS).
  • To identify factors associated with above-recommended antithrombotic dosing.
  • To inform strategies for improving antithrombotic therapy management in ACS patients.

Main Methods:

  • A mixed-methods study involving 36,682 patients with ACS from 135 Veterans Health Administration hospitals (2009-2011).
  • Quantitative analysis of antithrombotic dosing, including assessment of doses above recommended levels.
  • Qualitative interviews to explore provider perspectives on dosing challenges and CPOE use.

Main Results:

  • An average of 7.5% of patients received above-recommended doses of antithrombotics, with hospital-level variation from 0% to 32.0%.
  • Above-recommended UH doses were given to 1.2% of patients, while LMWH doses exceeded recommendations in 12.9% of patients.
  • Older age and higher BMI were linked to lower risk of excessive dosing, while resident-ordered antithrombotics increased this risk. Qualitative data emphasized the need for accurate weight-based dosing and CPOE training.

Conclusions:

  • Significant hospital-level variability exists in the administration of above-recommended doses of antithrombotics for ACS patients.
  • Findings underscore the importance of precise patient weight data and comprehensive provider education on CPOE for optimizing antithrombotic therapy.
  • Addressing dosing variability is essential for enhancing the safety and efficacy of ACS treatment.
Abstract

Keywords:
acute coronary syndromeantithromboticdosingquality of care

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