If not now, when? Prescription of evidence-based medical therapy prior to hospital discharge increases utilization at 6 months in patients with symptomatic peripheral artery disease

Abstract

Lower-extremity peripheral artery disease (PAD) results from narrowing of the blood vessels of the lower limbs, predominately secondary to atherosclerotic vascular disease. 1 The prevalence of lower-extremity (LE) PAD is increasing. 2 Patients with PAD are at increased risk of cardiovascular morbidity and mortality. 2 Risk factors associated with LE PAD are similar to those for atherosclerotic vascular disease elsewhere, and include age, smoking, diabetes mellitus, hyperlipidemia, and hypertension. 3 Evidence-based medical therapy (EBMT) is of crucial importance in reducing disease burden and limiting cardiovascular morbidity and mortality in this patient population. 2,4,5 Although EBMT is proven to lower cardiovascular morbidity and mortality and improve vascular outcome, use of this medical therapy is often suboptimal. AbstractWe evaluated the impact of the prescription of evidence-based medical therapy (EBMT) including aspirin (ASA), beta-blockers (BB), ACE-inhibitors or angiotensin receptor blockade (ACE/ARB), and statins prior to discharge after peripheral vascular intervention (PVI) on long-term medication utilization in a large multi-specialty, multicenter quality improvement collaborative. Among patients undergoing coronary revascularization, use of the component medications of EBMT at hospital discharge is a major predictor of long-term utilization. Predictors of EBMT use after PVI are largely unknown. A total of 10,169 patients undergoing PVI between 1 January 2008 and 31 December 2011 were included. Post-PVI discharge and 6-month medication utilization in patients without contra-indications to ASA, BB, ACE/ARB, and statins were compared. ASA was prescribed at discharge to 9345 (92%) patients, BB to 7012 (69%), ACE/ARB to 6424 (63%), and statins to 8342 (82%), and all four component drugs of EBMT in 3953 (39%). Compared with patients not discharged on the appropriate medications, post-procedural use was associated (all p<0.001) with reported 6-month use: ASA (84.5% vs 39.2%), BB (82.5% vs 11.1%), ACE/ARB (78.2% vs 11.8%), statins (84.6% vs 21.8%). Multivariable analysis revealed that prescription of EBMT at the time of discharge remained strongly associated with use at 6 months for each of the individual component drugs as well as for the combination of all four EBMT medications. In conclusion, prescription of the component medications of EBMT at the time of PVI is associated with excellent utilization at 6 months, while failure to prescribe EBMT at discharge is associated with low use of these medications 6 months later. These data suggest that the time of a PVI is a therapeutic window in which to prescribe EBMT in this high-risk cohort and represents an opportunity for quality improvement.

Statin prescription rates and their facility-level variation in patients with peripheral artery disease and ischemic cerebrovascular disease: Insights from the Department of Veterans Affairs

“…In this study, 21.8% of those not prescribed a statin at discharge were on statin therapy at the follow-up versus 84.6% of those who were prescribed statin therapy at discharge ( p <0.001). 26 In the absence of contraindications, inpatients with ASCVD should receive evidence-based medical therapies, including statins, before leaving the hospital.…”

Prescription of Guideline-Based Medical Therapies at Discharge After Carotid Artery Stenting and Endarterectomy

“…18 Because medication use was not measured after hospital discharge, it is not possible to ascertain long-term utilization rates for these agents or whether optimization (ie, statin dose escalation) occurred. Although it remains possible that patients discharged without antiplatelet therapy or a statin ultimately began taking these agents in the outpatient setting (the CARE registry does not ascertain medication utilization after hospital discharge, nor does it capture whether a physician recommended but did not prescribe a particular agent), this supposition has not borne out in clinical trials 19 or in registries 20 ; patients seem much more likely to use evidence-based medical therapies if they continue them from discharge than if they are left to initiate them in the outpatient setting.…”

Heterogeneity of Ankle-Brachial Indices in Patients Undergoing Revascularization for Critical Limb Ischemia

“…Briefly, BMC2 VIC is a statewide, prospective, multicenter, multispecialty quality improvement registry founded in October 2007. A more detailed description of this registry, including data collection and auditing practices, has been previously described (11). PVI was defined as endovascular treatment with angioplasty, atherectomy, or stent implantation.…”