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Beyond medication prescription as performance measures: optimal secondary prevention medication dosing after acute myocardial infarction.
J Am Coll Cardiol. 2013 Nov 05; 62(19):1791-801.JACC

Abstract

OBJECTIVES

The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI).

BACKGROUND

Current performance measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown.

METHODS

We assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (<50% target [defined from seminal clinical trials]), moderate (50% to 74% target), or goal (≥ 75% target). Patients with contraindications were excluded from analyses for that medication.

RESULTS

Most eligible patients (>87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval [CI]: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each.

CONCLUSIONS

Although nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI.

Authors+Show Affiliations

Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri. Electronic address: suz.v.arnold@gmail.com.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

23973701

Citation

Arnold, Suzanne V., et al. "Beyond Medication Prescription as Performance Measures: Optimal Secondary Prevention Medication Dosing After Acute Myocardial Infarction." Journal of the American College of Cardiology, vol. 62, no. 19, 2013, pp. 1791-801.
Arnold SV, Spertus JA, Masoudi FA, et al. Beyond medication prescription as performance measures: optimal secondary prevention medication dosing after acute myocardial infarction. J Am Coll Cardiol. 2013;62(19):1791-801.
Arnold, S. V., Spertus, J. A., Masoudi, F. A., Daugherty, S. L., Maddox, T. M., Li, Y., Dodson, J. A., & Chan, P. S. (2013). Beyond medication prescription as performance measures: optimal secondary prevention medication dosing after acute myocardial infarction. Journal of the American College of Cardiology, 62(19), 1791-801. https://doi.org/10.1016/j.jacc.2013.04.102
Arnold SV, et al. Beyond Medication Prescription as Performance Measures: Optimal Secondary Prevention Medication Dosing After Acute Myocardial Infarction. J Am Coll Cardiol. 2013 Nov 5;62(19):1791-801. PubMed PMID: 23973701.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Beyond medication prescription as performance measures: optimal secondary prevention medication dosing after acute myocardial infarction. AU - Arnold,Suzanne V, AU - Spertus,John A, AU - Masoudi,Frederick A, AU - Daugherty,Stacie L, AU - Maddox,Thomas M, AU - Li,Yan, AU - Dodson,John A, AU - Chan,Paul S, Y1 - 2013/08/21/ PY - 2013/02/11/received PY - 2013/04/10/revised PY - 2013/04/23/accepted PY - 2013/8/27/entrez PY - 2013/8/27/pubmed PY - 2014/1/8/medline KW - ACEI KW - AMI KW - ARB KW - CI KW - LDL-C KW - LV KW - OR KW - SBP KW - acute myocardial infarction KW - angiotensin II receptor blocker KW - angiotensin-converting enzyme inhibitor KW - confidence interval KW - left ventricular KW - low-density lipoprotein cholesterol KW - myocardial infarction KW - odds ratio KW - performance measures KW - secondary prevention KW - systolic blood pressure SP - 1791 EP - 801 JF - Journal of the American College of Cardiology JO - J Am Coll Cardiol VL - 62 IS - 19 N2 - OBJECTIVES: The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI). BACKGROUND: Current performance measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown. METHODS: We assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (<50% target [defined from seminal clinical trials]), moderate (50% to 74% target), or goal (≥ 75% target). Patients with contraindications were excluded from analyses for that medication. RESULTS: Most eligible patients (>87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval [CI]: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each. CONCLUSIONS: Although nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI. SN - 1558-3597 UR - https://www.unboundmedicine.com/medline/citation/23973701/Beyond_medication_prescription_as_performance_measures:_optimal_secondary_prevention_medication_dosing_after_acute_myocardial_infarction_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0735-1097(13)03788-1 DB - PRIME DP - Unbound Medicine ER -