Hospital-Level Factors Likely Explain Why Some VA Patients Don’t Get Timely Post-PCI Clopidogrel

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A new registry study of US Veterans Affairs (VA) hospitals shows that approximately 1 in 14 patients undergoing percutaneous coronary intervention (PCI) fails to fill his or her clopidogrel prescription on the day of hospital discharge. Wide variation in the length of delay at a hospital level suggests an opportunity to improve patient outcomes, which are adversely affected by the gap in thrombotic protection, researchers say in the paper published online June 9, 2014, ahead of print in American Heart Journal.

Methods

Investigators led by P. Michael Ho, MD, PhD, of the VA Eastern Colorado Health Care System (Denver, CO), reviewed data from the VA Clinical Assessment, Reporting, and Tracking (CART) program on more than 30,000 patients undergoing stenting at VA hospitals between January 1, 2005 and September 30, 2010. They excluded patients who might have had an alternate supply of clopidogrel at discharge, either from a prior prescription or by filling their prescription outside the VA system.


Among the 8,382 remaining patients, 7,775 (92.8%) filled their clopidogrel prescription on the day they left the hospital and 607 (7.2%) delayed between 1 and 30 days. Delays amounted to a mean of 14.4 days (SD 11.3 days) and median of 11 days (IQR 3-28 days). Patients who waited to obtain clopidogrel were more likely to have presented in cardiogenic shock (P < .001) and to have history of congestive heart failure (P < .02).

Delays Have Consequences

The combined rate of death/MI within 90 days of discharge was higher for patients who delayed than those who did not (14.0% vs 7.7%; P < .001); individual increases in both MI (11.5% vs 6.2%) and death (2.2% vs 1.5%) also occurred. Models treating clopidogrel delay as time independent and dependent suggested that the risk of death/MI changed over time in patients who waited to fill their prescription.

Delays varied substantially among hospitals; at some, all patients filled their prescription at discharge, while at others, nearly half (43.5%) delayed. The percentage of patients delaying clopidogrel did not correlate with hospital PCI volume.

Further calculations indicated that there were hospital-level factors affecting delay independent from patient-related factors; patients with identical characteristics being treated at one randomly selected hospital compared with another could have more than double the likelihood of delay (OR 2.13; 95% CI 1.85-2.68). None of the hospital-specific factors tested in logistic regression analysis—the number of beds, whether or not the site was a teaching hospital or offered cardiothoracic surgery, PCI volume, and overall patient volume—could explain the association.

Among patient-related factors, only history of congestive heart failure predicted delay (OR 1.42; 95% CI 1.08-1.87; P = .01).

Patient Education, Better Hospital Processes Needed

“Delays to filling clopidogrel after PCI can occur both within and outside of integrated healthcare systems,” Dr. Ho emphasized to TCTMD in an email. “In a prior study, 19.7% of Medicare patients did not fill a clopidogrel prescription within 7 days of hospital discharge, and in a study including 3 HMOs, 16% of patients had a delay in filling clopidogrel.”

The rate of 7.2% observed in the VA system is lower, he said, acknowledging that while this may well be a ‘best case scenario,’ it also “suggests that there are still potential opportunities for quality improvement.”

Since the study unearthed no clear hospital-related factors to explain the variation, the research team is “currently conducting some interviews at hospitals to better understand the processes for getting patients the prescribed medications including clopidogrel after PCI,” Dr. Ho reported.

As to how clinicians can encourage patients to promptly obtain clopidogrel, he said, education about why antiplatelet therapy is prescribed after PCI can make a difference. “Another important aspect is to try to decrease the barriers to filling a prescription at the time of hospital discharge. It may take a team to evaluate current discharge processes and then understand where there are potential barriers to patients getting their medication,” Dr. Ho continued, adding that VA researchers are evaluating whether having pharmacists bring antiplatelet drugs to the bedside or facilitate pickup at the pharmacy can improve adherence.

While the prevalence of delay seen here seems plausible, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), said in a telephone interview with TCTMD, a few aspects of the study design are unclear.

For example, he asked, did the researchers exclude patients who died before discharge? “The other methodological flaw that probably skews the numbers a little bit,” Dr. Brener noted, “is that they really should have [counted patients filling prescriptions] not just on the day of discharge but 1 day after as well because it’s possible that somebody who left [the hospital] at 5 in the afternoon and filled their prescription the next morning had uninterrupted therapy.”

That being said, the variability among hospitals is interesting and merits further study, he added.

 


Source:
Byrd JB, Maddox TM, O’Donnell CI, et al. Clopidogrel prescription filling delays and cardiovascular outcomes in a pharmacy system integrating inpatient and outpatient care: insights from the VA CART program.  Am Heart J. 2014;Epub ahead of print.

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Disclosures
  • Drs. Ho and Brener report no relevant conflicts of interest.

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