Beyond Medication Prescription as Performance Measures: Optimal Secondary Prevention Medication Dosing After AMI ONLINE FIRST

Abstract

Objective  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 following discharge after AMI is unknown.

Methods  We assessed treatment doses of beta-blockers, statins, and ACE/ARBs at discharge and 12 months after AMI among 6748 patients from 31 hospitals enrolled in 2 US registries (2003-08). Prescribed doses were categorized as none, low (<50% target [defined from seminal clinical trials]), moderate (50-74% 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 (∼25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACE/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% CI: 3.70-10.01); statins, adjusted OR: 8.22 (95% CI: 6.20-10.90); ACE/ARBs, adjusted OR: 5.80 (95% CI: 2.56-13.16); 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 may help improve the use of optimal medical therapy after AMI.

Source: content.onlinejacc.org