Variability in guideline-directed medical therapy across sites and operators and long-term mortality and amputation
Kim G Smolderen1, Gaëlle Romain2, Jacob Cleman2
1Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Department of Psychiatry, Psychology Section, Yale University School of Medicine, New Haven, CT.
Insights
Guideline-directed medical therapy (GDMT) use after peripheral vascular interventions (PVIs) varies significantly by provider and hospital, increasing patient risk for readmission, mortality, and amputation. Improving GDMT adherence is crucial for better patient outcomes.
Area of Science:
- Cardiovascular Medicine
- Health Services Research
- Vascular Surgery
Background:
- Guideline-directed medical therapy (GDMT) use in peripheral vascular interventions (PVIs) is associated with reduced mortality and amputation rates.
- Significant variability exists in GDMT prescription practices among healthcare sites and operators.
- The impact of this variability on patient outcomes, including readmissions and long-term mortality, requires further investigation.
Purpose of the Study:
- To analyze the association between site- and operator-level variability in GDMT prescription and patient outcomes following PVIs.
- To quantify the impact of inconsistent GDMT use on 90-day readmissions, 24-month mortality, and major amputation rates.
- To identify potential targets for quality improvement initiatives aimed at standardizing GDMT use.
Main Methods:
- Utilized Medicare-linked Vascular Quality Initiative registry data from 2017-2018 for patients undergoing PVIs.
- Defined GDMT as statin, antiplatelet therapy, and ACE inhibitor/ARB (if hypertensive).
- Quantified GDMT variability using median odds ratios (MOR) and intraclass correlation (ICC); analyzed associations with outcomes using logistic regression and survival models, adjusting for patient factors and including random effects for sites and operators.
Main Results:
- GDMT prescription rates varied widely (0%-38% to 57%-100%) across operators and sites, with 4% of variance attributed to site and operator levels.
- Lower GDMT rates demonstrated a dose-response relationship with increased 90-day readmission risk at both site and operator levels.
- Reduced site-level GDMT prescription correlated with higher 24-month mortality (HR=1.07) and major amputation (HR=1.08); similar associations were observed for operator-level use.
Conclusions:
- Significant variability in GDMT prescription exists at both operator and health system levels following PVIs.
- This variability is directly associated with increased risks of readmission, mortality, and major amputation.
- Quality improvement efforts must target both individual operators and healthcare sites to enhance GDMT use and improve patient outcomes after PVIs.
Background:
The use of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) decreases the risk of death and amputation and may decrease hospital readmissions. The variability of GDMT prescription across sites and operators and the proportionality of risk is not well understood. We aimed to study the association between variability of GDMT prescription at the site and operator level and outcomes (including 90-day readmissions and 24-month all-cause mortality and major amputation).
Methods:
We examined GDMT discharge rates in PVIs performed between 2017 and 2018 using Medicare-linked Vascular Quality Initiative registry. GDMT included a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-i/ARB) if hypertensive. Quartiles (Q1-4) of GDMT rates were documented by operators and sites and variability was quantified using median odds ratios (MOR) and intraclass correlation (ICC). The association between lower GDMT rates (per 10%) by sites and operators with 90-day readmission were calculated using logistic regression, and with 24-month mortality and major amputation using parametric survival model. Models were adjusted for patient-level factors and included sites and operators nested within sites as 2 random effects.
Results:
GDMT rates for 17,147 patients across 223 sites and 1,263 operators ranged from 0% to 38% (Q1, MOR 1.43, 95%CI 1.39-1.47, P ≤ .001) to 57%-100% (Q4, MOR 1.48, 95%CI 1.44-1.51, P ≤ .001). Four percent of variance in GDMT use was explained by sites (ICC 3.9, 95%CI 2.9-5.3) and operators (ICC 4.1, 95%CI 3.1-5.4). A dose-response relationship was noted between lower GDMT rates and increased risk of 90-day readmission risk by sites (P = .021) and operators (P < .001). Lower GDMT prescription by site was associated with higher risk of 24-month mortality (HR = 1.07, 95%CI 1.02-1.13) and major amputation (HR = 1.08, 95%CI 1.01-1.15). Similar associations were found for GDMT use by provider (mortality HR = 1.05, 95%CI 1.02-1.08 and amputation HR = 1.04, 95%CI 1.00-1.08).
Conclusion:
Both at the operator and health system level, there was significant variability in GDMT prescription following PVI, proportionally translating into risk for readmission, mortality, and major amputation. Targeted quality efforts should prioritize both operator and site levels to improve GDMT use and outcomes for patients undergoing PVI.
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