Lack of Physician Concordance With Guidelines on the Perioperative Use of β-Blockers

Siddiqui, Anam; Ahmed, Sheraz; Delbeau, Henri; Conner, David A.; Mattana, Joseph

doi:10.1001/archinte.164.6.664

Cited by 48 publications

(3 citation statements)

References 26 publications

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“…Data from observational studies and registries, however, show that the use of evidence-based medical therapy in the perioperative period remains suboptimal in this high-risk population. 10,13,20,21 Our results are in line with previous findings regarding disparities in risk factor management among patients with atherothrombotic disease. McDermott and colleagues previously reported that PAD patients received less intensive drug treatment compared to IHD patients, irrespective of comparable risk.…”

Section: Discussionsupporting

confidence: 90%

Medication Underuse During Long-Term Follow-Up in Patients With Peripheral Arterial Disease

Hoeks

Reimer

Gestel

et al. 2009

Circ: Cardiovascular Quality and Outcomes

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The use of guideline recommended therapies in the perioperative period was associated with reduction in long-term mortality in patients with peripheral arterial disease. However, the proportion of patients receiving these evidence-based treatments-both at baseline and 3 years after vascular surgery-was lower than expected based on the current guidelines. These data highlight a clear opportunity to improve the quality of care in this high-risk group of patients.

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Section: Discussionsupporting

confidence: 90%

Medication Underuse During Long-Term Follow-Up in Patients With Peripheral Arterial Disease

Hoeks

Reimer

Gestel

et al. 2009

Circ: Cardiovascular Quality and Outcomes

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“…The evidence is insufficient to recommend perioperative β blockers for patients at risk of cardiac morbidity. It is premature for policy making organisations to use treatment with perioperative β blocker as a measure of hospital quality 22 23. Therapeutic actions ought to await the perioperative ischemic evaluation study (POISE)24 and systematic reviews.…”

Section: Discussionmentioning

confidence: 99%

Effect of perioperative β blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial

Juul

Wetterslev

Gluud

et al. 2006

BMJ

320

125

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Objectives To evaluate the long term effects of perioperative blockade on mortality and cardiac morbidity in patients with diabetes undergoing major non-cardiac surgery. Design Randomised placebo controlled and blinded multicentre trial. Analyses were by intention to treat. Setting University anaesthesia and surgical centres and one coordinating centre. Participants 921 patients aged > 39 scheduled for major non-cardiac surgery. Interventions 100 mg metoprolol controlled and extended release or placebo administered from the day before surgery to a maximum of eight perioperative days. Main outcome measures The composite primary outcome measure was time to all cause mortality, acute myocardial infarction, unstable angina, or congestive heart failure. Secondary outcome measures were time to all cause mortality, cardiac mortality, and non-fatal cardiac morbidity. Results Mean duration of intervention was 4.6 days in the metoprolol group and 4.9 days in the placebo group. Metoprolol significantly reduced the mean heart rate by 11% (95% confidence interval 9% to 13%) and mean blood pressure by 3% (1% to 5%). The primary outcome occurred in 99 of 462 patients in the metoprolol group (21%) and 93 of 459 patients in the placebo group (20%) (hazard ratio 1.06, 0.80 to 1.41) during a median follow-up of 18 months (range 6-30). All cause mortality was 16% (74/462) in the metoprolol group and 16% (72/459) in the placebo group (1.03, 0.74 to 1.42). The difference in risk for the proportion of patients with serious adverse events was 2.4% ( − 0.8% to 5.6%). Conclusions Perioperative metoprolol did not significantly affect mortality and cardiac morbidity in these patients with diabetes. Confidence intervals, however, were wide, and the issue needs reassessment. Trial registration Current Controlled Trials ISRCTN58485613.

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“…Although these trials are currently underway, in the interim, patient safety groups continue to advocate for the administration of preoperative B‐blocker and the measurement of its use as a marker for quality of care 10–12 . To date, studies examining the current utilization of preoperative B‐blocker have been limited to single institution studies and database analysis of pharmacy and administrative data 13–15 . This study contributes to the literature by examining the use of a preoperative B‐blocker through a detailed chart review of patients undergoing noncardiac surgery in multiple, diverse institutions.…”

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confidence: 99%

Lack of adherence with preoperative B-blocker recommendations in a multicenter study

Kolodner

Cooper

et al. 2006

J Gen Intern Med

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BACKGROUND: Clinical guidelines support the use of preoperative B‐blocker in select patients. Patient safety groups have sought to measure the level of adherence to these recommendations. OBJECTIVE: This study was performed to compare the utilization of preoperative B‐blocker with current guidelines across multiple diverse institutions. DESIGN: Retrospective chart review was performed of inpatients undergoing noncardiac surgery across 5 hospital centers during 2003 to 2004. The primary outcome of interest was the administration of preoperative B‐blocker. PARTICIPANTS: The study sample included 1,304 randomly selected patients meeting the guideline criteria for preoperative B‐blockade. MEASUREMENTS AND MAIN RESULTS: Among patients meeting recommendations for preoperative B‐blocker, only 44% (430/983) received B‐blocker before surgery. Patients who had not previously received B‐blocker were given B‐blocker before surgery in only 14% (85/600) of cases. Target heart rates goals for perioperative B‐blockade were achieved in 26% (113/430) of cases. Predictors for initiating preoperative B‐blocker included nonelective surgery or a history of hypertension or diabetes. Individual hospitals were independently predictive of preoperative B‐blocker administration in multivariable models. CONCLUSIONS: Preoperative B‐blocker was significantly underutilized when compared with the current guideline recommendations. Target heart rate goals were not achieved in clinical practice, and few hospitalized patients had preoperative B‐blockade initiated. The lack of adherence to preoperative B‐blocker recommendations in practice may be impacted by ongoing clinical questions regarding the appropriate selection of candidates for this therapy. Further efforts toward achieving guideline recommendations for preoperative B‐blocker use should be focused on the subset of patients that are uniformly agreed upon to be at high risk for cardiac events.

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Lack of Physician Concordance With Guidelines on the Perioperative Use of β-Blockers

Abstract: Perioperative beta-blocker therapy is underutilized in patients with risk factors for coronary artery disease despite evidence that its use in appropriate individuals may be lifesaving.

Cited by 48 publications

References 26 publications

Medication Underuse During Long-Term Follow-Up in Patients With Peripheral Arterial Disease

Medication Underuse During Long-Term Follow-Up in Patients With Peripheral Arterial Disease

Effect of perioperative β blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial

Lack of adherence with preoperative B-blocker recommendations in a multicenter study

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