Author + information
- Received June 4, 2015
- Revision received August 17, 2015
- Accepted August 17, 2015
- Published online February 1, 2016.
- Jason H. Wasfy, MD, MPhila,b,∗ (, )
- Kevin F. Kennedy, MSc,
- Jennifer S. Chen, ABd,
- Timothy G. Ferris, MD, MPHa,e,
- Thomas M. Maddox, MD, MPHf and
- Robert W. Yeh, MD, MSca,g,∗∗ ()
- aCardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- bMassachusetts General Physicians Organization, Harvard Medical School, Boston, Massachusetts
- cSaint Luke’s Mid America Heart Institute/University of Missouri—Kansas City, Kansas City, Missouri
- dHarvard University, Cambridge, Massachusetts
- eDepartment of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- fCardiology Section, VA Eastern Colorado Health Care System/University of Colorado School of Medicine, Denver, Colorado
- gHarvard Clinical Research Institute, Boston, Massachusetts
Objectives The aim of this study was to test the hypothesis that in the United States substantial practice variation exists in triple therapy prescribing practices, unrelated to measured patient factors.
Background Recent data have shown that the risk of bleeding on dual antiplatelet therapy and oral anticoagulation (“triple therapy”) is high, although the optimal strategy for patients with atrial fibrillation and coronary artery disease remains unclear.
Methods Using the PINNACLE (National Practice Innovation and Clinical Excellence) registry, we identified 79,875 unique patients with both atrial fibrillation/atrial flutter and myocardial infarction and/or coronary stenting within 12 months. Using triple therapy as a binary outcome variable, we created a mixed-effects logistic regression model with patient factors as fixed effects and practice site as a random effect. Patient factors included age, sex, diabetes, congestive heart failure, hypertension, peripheral arterial disease, prior stroke or transient ischemic attack, history of systemic embolization, and dyslipidemia. The model was assessed with a median odds ratio to assess practice variation after adjustment for patient factors.
Results After adjustment for patient factors, significant practice variation was suggested by a median odds ratio of 2.78 (95% confidence interval: 2.33 to 3.23). In particular, this suggests that 2 randomly selected practices would differ in their likelihood of prescribing triple therapy for an identical patient by a factor of nearly 3.
Conclusions In the United States, there is substantial practice variation in prescribing triple therapy to eligible patients even after adjustment for patient clinical characteristics. These results suggest that opportunities exist to improve the quality of care of this sizable population.
This research was supported by the American College of Cardiology’s National Cardiovascular Data Registry (NCDR). The views expressed in this manuscript represent those of the author(s) and do not necessarily represent the official views of the NCDR or its associated professional societies identified at CVQuality.ACC.org/NCDR. The PINNACLE (National Practice Innovation and Clinical Excellence) registry is an initiative of the American College of Cardiology. Bristol-Myers Squibb and Pfizer, Inc. are founding sponsors of the PINNACLE registry. All authors have reported that they have no relationships relevant to the contents of this paper to disclose. Francis Marchlinski, MD, served as Guest Editor for this article.
- Received June 4, 2015.
- Revision received August 17, 2015.
- Accepted August 17, 2015.
- American College of Cardiology Foundation