Outpatient Prescription Practices in Patients with Atrial Fibrillation (From the NCDR PINNACLE Registry)

This study sought to evaluate inappropriate prescribing practices in an atrial fibrillation (AF) population, as outlined by the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter document. The 2016 AF quality measures document specified medications to avoid in certain AF populations, including aspirin and anticoagulant combination therapy in patients without cardiovascular disease, and non-dihydropyridine calcium channel blockers in patients with reduced ejection fraction. Using data from the NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed rates of inappropriate prescription of two types of medications among AF outpatients from 5/1/2008-5/1/2016. Overall rates of inappropriate prescription and variation by practice were calculated. Patient and practice factors associated with inappropriate prescription were assessed in adjusted analyses. A total of 107,759 of 658,250 (16.4%) patients without cardiovascular disease were inappropriately prescribed an antiplatelet and anticoagulant together, and 5,731 of 150,079 (3.8%) patients with reduced ejection fraction were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall, 14.8% of AF patients were prescribed medications that were not recommended. Both patient and practice factors were associated with inappropriate prescribing, and the adjusted practice-level median odds ratio for inappropriate prescription was 1.70 (95% CI: 1.61-1.82), indicating a 70% likelihood that 2 random practices would treat identical AF patients differently. In a large registry of AF patients treated in cardiology practices, overall rates of inappropriate prescription practices, as defined by the 2016 AF quality measures, were relatively low, but significant practice variation was present. This study sought to evaluate inappropriate prescribing practices in an atrial fibrillation (AF) population, as outlined by the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter document. The 2016 AF quality measures document specified medications to avoid in certain AF populations, including aspirin and anticoagulant combination therapy in patients without cardiovascular disease, and non-dihydropyridine calcium channel blockers in patients with reduced ejection fraction. Using data from the NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed rates of inappropriate prescription of two types of medications among AF outpatients from 5/1/2008-5/1/2016. Overall rates of inappropriate prescription and variation by practice were calculated. Patient and practice factors associated with inappropriate prescription were assessed in adjusted analyses. A total of 107,759 of 658,250 (16.4%) patients without cardiovascular disease were inappropriately prescribed an antiplatelet and anticoagulant together, and 5,731 of 150,079 (3.8%) patients with reduced ejection fraction were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall, 14.8% of AF patients were prescribed medications that were not recommended. Both patient and practice factors were associated with inappropriate prescribing, and the adjusted practice-level median odds ratio for inappropriate prescription was 1.70 (95% CI: 1.61-1.82), indicating a 70% likelihood that 2 random practices would treat identical AF patients differently. In a large registry of AF patients treated in cardiology practices, overall rates of inappropriate prescription practices, as defined by the 2016 AF quality measures, were relatively low, but significant practice variation was present. Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and is associated with significant morbidity and mortality.1Krahn AD Manfreda J Tate RB Mathewson FA Cuddy TE The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the manitoba follow-up study.Am J Med. 1995; 98: 476-484Abstract Full Text PDF PubMed Scopus (1217) Google Scholar,2Rahman F Kwan GF Benjamin EJ Global epidemiology of atrial fibrillation.Nat Rev Cardiol. 2014; 11: 639-654Crossref PubMed Scopus (333) Google Scholar Among patients with AF, many outpatient treatments exist to improve clinical outcomes, and include medication prescription for either rate or rhythm control and oral anticoagulation prescription for stroke risk reduction.3Wyse DG Waldo AL DiMarco JP Domanski MJ Rosenberg Y Schron EB Kellen JC Greene HL Mickel MC Dalquist JE Corley SD Atrial fibrillation follow-up investigation of rhythm management I. A comparison of rate control and rhythm control in patients with atrial fibrillation.N Engl J Med. 2002; 347: 1825-1833Crossref PubMed Scopus (3456) Google Scholar, 4Hart RG Pearce LA Aguilar MI Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.Ann Intern Med. 2007; 146: 857-867Crossref PubMed Scopus (3379) Google Scholar, 5Ruff CT Giugliano RP Braunwald E Hoffman EB Deenadayalu N Ezekowitz MD Camm AJ Weitz JI Lewis BS Parkhomenko A Yamashita T Antman EM Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.Lancet. 2014; 383: 955-962Abstract Full Text Full Text PDF PubMed Scopus (2773) Google Scholar However, prescription of these medications may have serious side effects, thus safe prescription of these medications is important as worse clinical outcomes may arise when specific medications are prescribed to incorrect patients. AF clinical practice guidelines and quality measures call for safe use of these medications and warn against inappropriate prescription in specific patient populations who may be at risk for harm.6January CT Wann LS Alpert JS Calkins H Cigarroa JE Cleveland J Joseph C Conti JB Ellinor PT Ezekowitz MD Field ME Murray KT Sacco RL Stevenson WG Tchou PJ Tracy CM Yancy CW 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation A report of the American college of cardiology/American heart association task force on practice guidelines and the heart rhythm society.J Am Coll Cardiol. 2014; 64: e1-e76Crossref PubMed Scopus (2495) Google Scholar, 7January CT Wann LS Calkins H Chen LY Cigarroa JE Cleveland Jr., JC Ellinor PT Ezekowitz MD Field ME Furie KL Heidenreich PA Murray KT Shea JB Tracy CM Yancy CW 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart rhythm society.J Am Coll Cardiol. 2019; 74: 104-132Crossref PubMed Scopus (596) Google Scholar, 8Heidenreich PA Solis P Estes 3rd, NAM Fonarow GC Jurgens CY Marine JE McManus DD McNamara RL 2016 ACC/AHA clinical erformance and quality measures for adults with atrial fibrillation or atrial flutter: a report of the American college of cardiology/American heart association task force on performance measures.J Am Coll Cardiol. 2016; 68: 525-568Crossref PubMed Scopus (40) Google Scholar Most recently, the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter was published with the goal of benchmarking and improving the quality of care for patients with AF.8Heidenreich PA Solis P Estes 3rd, NAM Fonarow GC Jurgens CY Marine JE McManus DD McNamara RL 2016 ACC/AHA clinical erformance and quality measures for adults with atrial fibrillation or atrial flutter: a report of the American college of cardiology/American heart association task force on performance measures.J Am Coll Cardiol. 2016; 68: 525-568Crossref PubMed Scopus (40) Google Scholar Some of these performance and quality measures specifically focus on safe AF prescribing practices by outlining which AF treatments are inappropriate for particular patient populations. Accordingly, we investigated safe outpatient prescribing practices in AF patients by analyzing data from the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) Registry, the largest outpatient quality improvement registry of patients treated in cardiology clinics in the United States. First, we assessed the rates of inappropriate prescription of AF treatments among PINNACLE patients, as outlined in the 2016 AF quality measures document. Second, we described practice-level rates and variation of inappropriate prescription practices. Finally, we characterized patient and practice factors associated with inappropriate prescription practices. Our analysis used data from the NCDR PINNACLE registry to assess prescription patterns in a large, contemporary outpatient registry. The NCDR PINNACLE registry was created in 2008 by the American College of Cardiology as the first national, prospective, office-based cardiac quality improvement registry of patients seen in cardiology practices in the United States.9Chan PS Oetgen WJ Buchanan D Mitchell K Fiocchi FF Tang F Jones PG Breeding T Thrutchley D Rumsfeld JS Spertus JA Cardiac performance measure compliance in outpatients: the American college of cardiology and national cardiovascular data registry's PINNACLE (Practice innovation and clinical excellence) program.J Am Coll Cardiol. 2010; 56: 8-14Crossref PubMed Scopus (123) Google Scholar Participating practices collect longitudinal, point-of-care data for each outpatient visit that includes patient demographics, symptoms, comorbidities, vital signs, medications, laboratory values, and recent hospitalizations. Data is collected directly from participating practices’ electronic health record using a standardized collection tool to comprehensively obtain and transmit uniform data. NCDR registry data quality assurance is maintained through standardized data collection and transmission protocols, rigorous data definitions and periodic data quality audits.10Messenger JC Ho KK Young CH Slattery LE Draoui JC Curtis JP Dehmer GJ Grover FL Mirro MJ Reynolds MR Rokos IC Spertus JA Wang TY Winston SA Rumsfeld JS Masoudi FA The national cardiovascular data registry (NCDR) data quality brief: the NCDR data quality program in 2012.J Am Coll Cardiol. 2012; 60: 1484-1488Crossref PubMed Scopus (250) Google Scholar,11Maddox TM Song Y Allen J Chan PS Khan A Lee JJ Mitchell J Oetgen WJ Ponirakis A Segawa C Spertus JA Thorpe F Virani SS Masoudi FA Trends in U.S. ambulatory cardiovascular care 2013 to 2017: JACC review topic of the week.J Am Coll Cardiol. 2020; 75: 93-112Crossref PubMed Scopus (3) Google Scholar For our study, we assessed patient and practice level data collected during the first clinic visit that a patient had AF or atrial flutter listed as a diagnosis between May 2008 and May 2016, as recorded in PINNACLE. AF was defined by the treating clinician and also included a history of atrial flutter. We excluded patients <18 years old, those with missing gender, and/or those treated in practices with <10 total AF patients. Our primary outcome was the inappropriate prescription of medications among AF patients, as outlined in the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter.8Heidenreich PA Solis P Estes 3rd, NAM Fonarow GC Jurgens CY Marine JE McManus DD McNamara RL 2016 ACC/AHA clinical erformance and quality measures for adults with atrial fibrillation or atrial flutter: a report of the American college of cardiology/American heart association task force on performance measures.J Am Coll Cardiol. 2016; 68: 525-568Crossref PubMed Scopus (40) Google Scholar Specifically, we assessed the inappropriate prescription of antiplatelet and oral anticoagulant combination therapy for patients who do not have coronary artery disease and/or vascular disease, and inappropriate prescription of non-dihydropyridine calcium channel antagonist in patients with reduced ejection fraction heart failure. Although an update to the performance and quality measures document was published in 2020, none of the inappropriate prescriptions analyzed were changed.12Writing Committee M Heidenreich PA Estes 3rd, NAM Fonarow GC Jurgens CY Kittleson MM Marine JE McManus DD McNamara RL 2020 Update to the 2016 ACC/AHA clinical performance and quality measures for adults with atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.J Am Coll Cardiol. 2021; 77: 326-341Crossref PubMed Scopus (1) Google Scholar Patient factors potentially associated with inappropriate prescription practices in AF patients were selected based on clinical reasoning. These factors included demographics (age, sex, race, insurance payer) and clinical characteristics (smoking status, heart failure, hypertension, diabetes, prior stroke and/or transient ischemic attack, coronary artery disease, peripheral artery disease, dyslipidemia, and use of rhythm control therapy). Practice factors included provider type (physician vs. nurse-practitioner or physician-assistant), U.S. practice region (Midwest, Northeast, South, or West), practice location (urban, suburban, or rural), and practice patient volume. For our overall study cohort, summary statistics of patients’ and practice characteristics were reported as means with standard deviations for continuous variables and proportions for categorical variables. For each measure, we determined those AF patients in PINNACLE who were eligible for a given measure (e.g. all AF patients with reduced ejection fraction heart failure). Patients with a documented medical, patient, or system contraindication for the prescribed medication were excluded from analyses for that particular measure. Then, the number of patients who were receiving the inappropriate medication prescription was then divided into the eligible population. Thus, the optimal rate for any given measure was 0%. We analyzed the rates of the two quality measures in our cohort, first individually and then in combination. The combined inappropriate prescription rate was defined and calculated using a modification of the Joint Commission's “quality opportunities” metric, thus ensuring that only eligible patients were included in the relevant calculation.13Kahn 3rd, CN Ault T Isenstein H Potetz L Van Gelder S Snapshot of hospital quality reporting and pay-for-performance under Medicare.Health Aff (Millwood). 2006; 25: 148-162Crossref PubMed Scopus (77) Google Scholar At the practice level, median individual and combined inappropriate prescription rates and ranges were calculated and examined with descriptive plots. Multivariable regression models were constructed to assess associations between patient factors, practice factors, and inappropriate prescription rates. Hierarchical modeling was used to account for clustering of patients by practice. Practice was modeled as a random rather than fixed effect. Practice variation in prescription rates by practice sites was calculated using a median odds ratio (MOR). The MOR estimates the differences between compliance patterns for identical patients between 2 randomly selected practices. It can be interpreted as the likelihood ratio that the same patient would receive a different combination of treatment at 2 different practices in our cohort. An MOR of 1.0 indicates that no variation exists between practices. In contrast, an MOR of 1.5 indicates a 50% likelihood that a similar patient would receive differential compliance at 2 different practices. It provides an estimate of the effect size of the practice on the outcome, much as the odds ratio estimates the effect size of patient factors on the outcome. Based on prior literature, an MOR >1.2 indicates clinically significant variation.14Maddox TM Chan PS Spertus JA Tang F Jones P Ho PM in coronary artery disease prescriptions among outpatient cardiology from the NCDR Cardiovascular Data Am Coll Cardiol. 2014; PubMed Scopus Google Scholar missing data rates in our included for insurance for race, and 14.8% for were and significant a were using the of and for study was by an review 2008 and 2016, the PINNACLE registry data for a total patients seen in practices, of which were patients with of patients <18 years missing and treated by practices with <10 total AF patients our study for analysis patients with AF characteristics of the study are in The of the study was years with the of race, and The was at in the of patients and were common including with hypertension, with diabetes, with coronary artery disease and with The median number of patients from each practice was of to the practices, all were cardiology practices, and practices were in and or patient and practice Patients or ischemic artery coronary artery or coronary than of control control rate oral antiplatelet therapy channel and Practice by by or data are reported as data are reported as coronary artery in a new data are reported as data are reported as coronary artery prescription rates for each measure are listed in AF patients who not have coronary artery disease and/or vascular disease, 107,759 (16.4%) were inappropriately prescribed an antiplatelet and oral anticoagulant and of AF patients with reduced ejection 5,731 (3.8%) were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall combined rates of inappropriate prescriptions were and combined inappropriate prescription of and and/or of in Patients with Heart each of the 2 atrial fibrillation quality measures, rates of inappropriate use were The for these rates was the total number of patients that the for inappropriate use for the quality measure, and the for these rates was the total number of eligible patients at risk for inappropriate use for that quality measure. Measures were assessed at the patient in a new For each of the 2 atrial fibrillation quality measures, rates of inappropriate use were The for these rates was the total number of patients that the for inappropriate use for the quality measure, and the for these rates was the total number of eligible patients at risk for inappropriate use for that quality measure. Measures were assessed at the patient rates and ranges for inappropriate prescription rates for each measure are listed in The median practice rate of inappropriate prescription of antiplatelet and oral anticoagulation therapy for patients who do not have coronary artery disease and/or vascular disease was with an of The median practice rate of inappropriate prescription of calcium channel antagonist in patients with reduced ejection fraction heart was with an of The median practice rate of inappropriate prescription measures was with an of rates of combined inappropriate prescription of all 2 The each of the individual practices from to with to rate of inappropriate and the the practice-level prescription AF, atrial AF, atrial In adjusted patient factors associated with rates of inappropriate prescriptions measures included vs. odds ratio insurance type coronary artery disease and peripheral disease Patient factors associated with rates of inappropriate prescriptions measures included heart prior ischemic and rhythm control therapy practice variation was in each of the inappropriate prescription For inappropriate prescription of antiplatelet and oral anticoagulation therapy for patients who do not have coronary artery disease and/or vascular disease, adjusted practice median odds ratio was (95% For inappropriate prescription of calcium channel antagonist in patients with reduced ejection fraction heart failure, adjusted practice MOR was (95% For inappropriate prescription rates among measures, the adjusted practice MOR was 1.70 (95% factors associated with inappropriate prescription of (95% vs. vs. vs. vs. or vs. of Heart of of of of of of in a new In a national outpatient cardiology practice registry, we that safe AF prescribing practices were with inappropriate prescriptions in only in patients. However, significant practice variation in inappropriate prescription was In patient factors and practice were associated with prescription practices. In was a 70% likelihood that different practices would have different combined quality measure compliance for similar patients. These that may exist for improvement in the safe prescription of AF treatments by practices. The most inappropriate prescription rate was seen in antiplatelet and oral anticoagulation therapy for patients who do not have coronary artery disease and/or vascular This that cardiovascular patients may be prescribed an antiplatelet on of oral anticoagulation when is not the of without improvement in stroke risk CH aspirin and anticoagulant therapy in patients with atrial PubMed Scopus Google Scholar This in L M D P S M K S Lewis BS JJ P H PG L vs. warfarin with aspirin in patients with atrial fibrillation: from the Heart 2014; PubMed Scopus (123) Google Scholar and may that are to the of antiplatelet efficacy in primary and the risk that with EJ A D MD D Jr., Virani SS J 2019 ACC/AHA guideline on the primary of cardiovascular a report of the American college of cardiology/American heart association task force on clinical practice Am Coll Cardiol. 2019; 74: PubMed Scopus Google AL L S J M Ezekowitz M J PA S use of antiplatelet therapy with or warfarin in the of anticoagulation therapy PubMed Scopus Google Scholar Finally, rates of inappropriate prescription were with a calcium channel antagonist in patients with reduced ejection fraction heart failure, as only of patients were inappropriately prescribed these that heart based guidelines of calcium channel in patient are not Committee M Yancy CW M J Jr., Fonarow GC SA T MR Masoudi FA JJ Mitchell JE F Stevenson Tang EJ American college of cardiology heart association task force on practice 2013 guideline for the management of heart a report of the American college of cardiology heart association task force on practice PubMed Scopus Google Scholar Our study also variation in inappropriate prescription patterns of AF medications by practice have similar practice variation in cardiac performance and quality measures, but is the first study to among safe AF prescribing PS Oetgen WJ Buchanan D Mitchell K Fiocchi FF Tang F Jones PG Breeding T Thrutchley D Rumsfeld JS Spertus JA Cardiac performance measure compliance in outpatients: the American college of cardiology and national cardiovascular data registry's PINNACLE (Practice innovation and clinical excellence) program.J Am Coll Cardiol. 2010; 56: 8-14Crossref PubMed Scopus (123) Google Scholar These that a patient may to a 70% variation in care in different PINNACLE practices for AF variation may be an of given that PINNACLE registry is and thus selected for practices in Thus, these the for in the care of AF patients, and specific that the of practice variation for AF prescription focus on characteristics that may inappropriate prescription of medications in AF patients, as status, and size of AF management guidelines were published in 2019 and may clinical practice. Our study to the of cardiovascular care in the outpatient Chan care patterns for cardiac outpatients with and AF, also using the PINNACLE registry. significant variation in with compliance for most PS Oetgen WJ Buchanan D Mitchell K Fiocchi FF Tang F Jones PG Breeding T Thrutchley D Rumsfeld JS Spertus JA Cardiac performance measure compliance in outpatients: the American college of cardiology and national cardiovascular data registry's PINNACLE (Practice innovation and clinical excellence) program.J Am Coll Cardiol. 2010; 56: 8-14Crossref PubMed Scopus (123) Google Scholar A recent investigation of patients in the PINNACLE registry also significant and variation in prescription TM Chan PS Spertus JA Tang F Jones P Ho PM in coronary artery disease prescriptions among outpatient cardiology from the NCDR Cardiovascular Data Am Coll Cardiol. 2014; PubMed Scopus Google Scholar In the national to improve and stroke care among outpatient were practice-level differences that were in antiplatelet treatment and with and L AF quality of cardiovascular for an analysis of outpatients from the guideline Heart 2014; PubMed Scopus Google Scholar Our study these into the of quality care by the safety of in an AF that not as as Although the overall rates of inappropriate prescription practices are relatively the prescription variation by practice that are important that can be at the patient and provider level to avoid prescription of medications to AF patients. Our study First, of our may be to of medication prescription in AF patients. a our rates of inappropriate prescriptions may be Second, the PINNACLE program patients from cardiology practices to quality improvement and may not the practice of AF prescription practice among prescription rates may be in the practice the PINNACLE Registry data specific practice and we were to on characteristics of and practices. AF treatment guidelines in during the study not a for aspirin with oral anticoagulant and data risk of had during the study we that the 2016 AF quality measure document may to a practice that may not have during the study of Finally, not all quality measures in the 2016 AF document were to be to specific data not collected in the PINNACLE Registry, our to all of the safe prescribing practices in the In in a large, registry of AF patients treated by participating in the PINNACLE Registry, inappropriate prescription rates of AF medications were relatively was significant variation in prescription patterns by in differences in similar patients would be treated by different practices. These of quality measure improvement in the prescription of medications for AF to safe and into the practice-level differences in care of the AF patients of which practice the patients