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Variation in CAD Secondary Prevention Prescription Among Outpatient Cardiology Practices: Insights From the NCDR®
Study Questions:
What is the practice variation of secondary prevention medication prescription (statins, beta-blockers, angiotensin-converting enzyme inhibitors, and angiotensin-receptor blockers) among coronary artery disease (CAD) patients treated in outpatient practices?
Methods:
Using data from the NCDR® PINNACLE Registry®, a national outpatient cardiology practice registry, the authors 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. Use of evidence-based treatment was defined as within 1 year of the index event (myocardial infarction, coronary artery bypass grafting, or percutaneous coronary intervention).
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 at the time of the index clinic visit. 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% confidence interval, 1.2-1.32), indicating a 25% likelihood that two 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.
Perspective:
Optimal practice was defined as number of prescriptions divided by the number for which the patient was eligible (maximal of three) with exclusion of patients for whom there was documentation for not prescribing one or more medication classes. Among the variables not reported that could have influenced the outcome is whether the cardiologist shared the patient with a primary care physician. That the median rate of optimal practice by cardiologists who are aware that their practices are being monitored is less than 75%, speaks volumes to the failure of guidelines and monitoring to impact practice, the failure of knowledge to convert to practice, and the high probability of much worse data in primary care practices whose practice patterns are not being monitored. These results support the concept of financial penalties for physicians whose practice pattern does not meet acceptable standards. One obvious concern of all physicians is the degree to which the electronic medical record may be in error.
Keywords: Angiotensin Receptor Antagonists, Myocardial Infarction, Coronary Artery Disease, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Coronary Disease, Percutaneous Coronary Intervention, Cardiovascular Diseases, Coronary Artery Bypass, Bufanolides
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