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Abstract 257: Practice Variation is a Significant Contributor to Secondary Prevention Medication Use: Insights from the NCDR PINNACLE Program


 Background:
 Secondary prevention medications for eligible CAD patients include antiplatelets, lipid lowering agents, beta-blockers (BB) and angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). However, use of these therapies is variable. The contribution of practice-level factors to variation in medication use is unknown. In addition, the contribution of practice-level factors relative to patient factors is also unknown.
 
 
 Methods:
 We evaluated CAD patients in cardiology practices participating in the NCDR PINNACLE program, a national office-based cardiac quality improvement registry, between July 2008 and December 2010. Patients eligible for treatment were grouped by Class I indications for therapy: antiplatelets and lipid lowering agents in all, BBs in post-MI patients, and ACEIs/ARBs in those with diabetes or with reduced left ventricular ejection fraction (≤40%). Mean practice rates of therapy use were calculated. Next, hierarchical regression models assessed the effect of practice on therapy use, adjusted for patient factors, using the median rate ratio (MRR). The MRR compares the likelihood of treatment for identical patients from two randomly selected practices. In general, MRRs ≥ 1.2 indicate significant variation by practice. Finally, the magnitude of contribution of patient factors, expressed in ORs, to variation in therapy use was assessed.
 
 
 Results:
 Our cohort consisted of 277,526 patients in 62 practices. The mean practice rate was 80.8% for antiplatelets (range 41.2–100%), 79.5% for lipid lowering agents (range 33.9–100%), 77.6% for BBs (range 35.2–100%), and 73.8% for ACEI/ARBs (range 39.1–100%). Adjusted MRR between practices was 1.19 for antiplatelets, 1.19 for lipid lowering agents, 1.20 for BBs, and 1.19 for ACEIs/ARBs. Almost all patient-level factors were smaller in magnitude than the MRR for practice-level variation (see Table).
 
 
 Conclusions:
 Among practices participating in the PINNACLE program, significant variation in guideline recommended treatments among CAD outpatients exists. Practice setting, independent of patient factors, was associated with variation in treatment and was similar in magnitude to most patient factors. Our findings suggest that practice setting is an important contributor to variability in secondary prevention medication use. Accordingly, to improve the use of evidence-based CAD therapies, quality improvement efforts targeting practice-level factors should be evaluated.
 
 
 
