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Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7

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Abstract

Purpose

We investigated facility-level variation in the use and adherence with antiplatelets and statins among patients with premature and extremely premature ASCVD.

Methods

Using the 2014–2015 nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed patients with premature (age at first ASCVD event: males < 55 years, females < 65 years) and extremely premature ASCVD (< 40 years). We examined frequency and facility-level variation in any statin, high-intensity statin (HIS), antiplatelet use (aspirin, clopidogrel, ticagrelor, prasugrel, and ticlopidine), and statin adherence (proportion of days covered ≥ 0.8) across 130 nationwide VA healthcare facilities. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of statins or antiplatelets and statin adherence.

Results

Our analysis included 135,703 and 7716 patients with premature and extremely premature ASCVD, respectively. Across all facilities, the median (IQR) prescription rate of any statin therapy, HIS therapy, and antiplatelets among patients with premature ASCVD was 0.73 (0.70–0.75), 0.36 (0.32–0.41), and 0.77 (0.73–0.81), respectively. MRR (95% CI) for any statin use, HIS use, and antiplatelet use were 1.53 (1.44–1.60), 1.58 (1.49–1.66), and 1.49 (1.42–1.56), respectively, showing 53, 58, and 49% facility-level variation. The median (IQR) facility-level rate of statin adherence was 0.58 (0.55–0.62) and MRR for statin adherence was 1.13 (1.10–1.15), showing 13% facility-level variation. Similar median facility-level rates and variation were observed among patients with extremely premature ASCVD.

Conclusions

There is suboptimal use and significant facility-level variation in the use of statin and antiplatelet therapy among patients with premature and extremely premature ASCVD. Interventions are needed to optimize care and minimize variation among young ASCVD patients.

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Data Availability

The datasets generated during and/or analyzed during the current study are not publicly available as our dataset encompasses the nationwide Veterans Affairs data. We are, hence, unable to provide our complete dataset.

Abbreviations

ASCVD:

Atherosclerotic cardiovascular disease

BMI:

Body mass index

CI:

Confidence interval

CPT:

Current procedural terminology

DCG-RRS:

Diagnosis Cost Group Relative Risk Score

ICD-9 CM:

International Classification of Diseases, Ninth Revision, Clinical Modification

ICVD:

Ischemic cerebrovascular disease

IHD:

Ischemic heart disease

MRR:

Median rate ratios

PAD:

Peripheral arterial disease

VA:

Veterans Affairs

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Acknowledgments

The authors would also like to thank Mark Kuebeler, MS, for his programming efforts in generation of this manuscript’s results.

Funding

This work was supported by a Department of Veterans Affairs Health Services Research & Development Service Investigator Initiated Grant (IIR 16–072), an American Heart Association Beginning Grant-in-Aid (14BGIA20460366), the American Diabetes Association Clinical Science and Epidemiology award (1–14- CE-44), and the Houston VA Health Services Research & Development Center for Innovations grant (CIN13–413).

Support for VA/CMS data provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02–237 and 98–004). The opinions expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs or the US government.

Author information

Authors and Affiliations

  1. Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, 2002 Holcombe Blvd, Houston, TX, 77030, USA

    Dhruv Mahtta, Michelle T. Lee, David J. Ramsey, Julia M. Akeroyd, Laura A. Petersen & Salim S. Virani

  2. Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Dhruv Mahtta, Michelle T. Lee, Chayakrit Krittanawong, Mahboob Alam, Christie M. Ballantyne & Salim S. Virani

  3. Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, USA

    Safi U. Khan

  4. Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA

    Preetika Sinh

  5. Center for Heart and Vascular Health, ChristianaCare, Newark, DE, USA

    Kirk N. Garratt

  6. Division of Cardiovascular Medicine, University of Florida, Gainesville, FL and Department of Veterans Affairs Medical Center, Gainesville, FL, USA

    Richard S. Schofield

  7. Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Christie M. Ballantyne & Salim S. Virani

  8. Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA

    Salim S. Virani

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  1. Dhruv Mahtta
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Contributions

Conceptualization: Dhruv Mahtta, Laura A. Petersen, Salim S. Virani.

Methodology: Dhruv Mahtta, David J. Ramsey, Salim S. Virani.

Formal analysis and investigation: Dhruv Mahtta, David J. Ramsey, Salim S. Virani.

Writing—original draft preparation: Dhruv Mahtta, Michelle T. Lee, Salim S. Virani.

Writing—review and editing: Dhruv Mahtta, Michelle T. Lee, Julia M. Akeroyd, Chayakrit Krittanawong, Safi U. Khan, Preetika Sinh, Mahboob Alam, Kirk N. Garratt, Richard S. Schofield, Christie M. Ballantyne, Laura A. Petersen, Salim S. Virani.

Funding acquisition: Salim S. Virani.

Resources: Mahboob Alam, Kirk N. Garratt, Richard S. Schofield, Christie M. Ballantyne, Laura A. Petersen.

Supervision: Richard S. Schofield, Christie M. Ballantyne, Laura A. Petersen, Salim S. Virani.

Corresponding author

Correspondence to Salim S. Virani.

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Conflict of Interest

Dhruv Mahtta, Michelle T. Lee, David J. Ramsey, Chayakrit Krittanawong, Julia M. Akeroyd, Safi U. Khan, Preetika Sinh, Mahboob Alam, Kirk N. Garratt, Richard S. Schofield, Laura A. Petersen: None.

Christie M. Ballantyne: Grant/Research Support—all significant (all paid to institution, not individual): Akcea, Amgen, Esperion, Novartis, Regeneron, Sanofi-Synthelabo, NIH, AHA, ADA.

Consultant—Abbott Diagnostics, Akcea, Amarin, Amgen, Arrowhead, Astra Zeneca, Corvidia, Denka Seiken, Esperion, Intercept, Matinas BioPharma Inc., Merck, Novartis, Regeneron, Sanofi-Synthelabo.

Salim S. Virani: Honorarium, American College of Cardiology (Associate Editor for Innovations, acc.org); Steering Committee, Patient and Provider Assessment of Lipid Management (PALM registry) at the Duke Clinical Research Institute (no financial remuneration).

Ethics Approval

The institutional review boards at Baylor College of Medicine and the Michael E. DeBakey VA Medical Center approved the study protocol. An approval was also obtained for the informed consent waiver.

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Mahtta, D., Lee, M.T., Ramsey, D.J. et al. Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7. Cardiovasc Drugs Ther 36, 93–102 (2022). https://doi.org/10.1007/s10557-020-07125-3

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