Underutilization of Aspirin Persists in US Ambulatory Care for the Secondary and Primary Prevention of Cardiovascular Disease

Abstract

BackgroundDespite the proven benefits of aspirin therapy in the primary and secondary prevention of cardiovascular disease (CVD), utilization rates of aspirin remain suboptimal in relation to recommendations. We studied national trends of aspirin use among intermediate- to high-risk patients in the US ambulatory care settings and compared the priority given to aspirin versus statins for CVD risk reduction. We also examined patient and health care provider contributors to the underuse of aspirin.Methods and FindingsWe used the 1993–2003 US National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to estimate aspirin use by cardiovascular risk. Physician-noted cardiovascular diseases defined high risk. Intermediate risk was defined as having diabetes mellitus or multiple major risk factors. The proportion of patient visits in which aspirin was reported increased from 21.7% (95% confidence interval: 18.8%–24.6%) in 1993–1994 to 32.8% (25.2%–40.4%) in 2003 for the high-risk category, 3.5% (2.0%–5.0%) to 11.7% (7.8%–15.7%) for visits by patients diagnosed with diabetes, and 3.6% (2.6%–4.6%) to 16.3% (11.4%–21.2%) for those with multiple CVD risk factors. Beginning in 1997–1998, statins were prioritized over aspirin as prophylactic therapy for reducing CVD risk, and the gaps remained wide through 2003. In addition to elevated CVD risk, greater aspirin use was independently associated with advanced age, male gender, cardiologist care, and care in hospital outpatient departments.ConclusionImprovements in use of aspirin in US ambulatory care for reducing risks of CVD were at best modest during the period under study, particularly for secondary prevention, where the strongest evidence and most explicit guidelines exist. Aspirin is more underused than statins despite its more favorable cost-effectiveness. Aggressive and targeted interventions are needed to enhance provider and patient adherence to consensus guidelines for CVD risk reduction.

Antiplatelet and Statin Use in US Patients With Coronary Artery Disease Categorized by Race/Ethnicity and Gender, 2003 to 2012

“…14 Meanwhile, our study finds similar levels of antiplatelet treatment to that of previous studies 15e17 but higher levels of use compared with a previous studies relying on National Ambulatory Medical Care Survey. 7,18 This difference is likely related to the self-report of aspirin in MEPS compared with physician records in NAMCS.…”

Quality of US Primary Care Delivered by Resident and Staff Physicians

“…This confirms previously identified gaps in compliance with evidence-based guidelines for blood pressure screening, 15 diet and exercise counseling, 16 statin use for moderate to high risk patients, 17 and aspirin use for primary and secondary prevention of cardiovascular disease. 1,18,19 Resident physicians provide a disproportionate amount of care for vulnerable populations. In our study, residents were more likely than staff physicians to care for non-white and Medicaid patients, which is consistent with prior studies.…”

Antiplatelet and anticoagulant nonuse for acute myocardial infarction in the emergency department: An analysis from the National Hospital Ambulatory Medical Care Survey, 2002-2010

“…Furthermore, in ISIS-2, there was a higher reduction in mortality with early acetylsalicylic acid and streptokinase use (0 h to 4 h) compared with treatment 5 h to 12 h and 13 h to 24 h after the symptom onset. Similarly, in the Argatroban in Acute Myocardial Infarction-2 study, early acetylsalicylic acid use (1.6 h versus 3.5 h) was associated with significant reduction in mortality at seven days, 30 days and one year of follow-up (20). In our study, the mean length of ED visits for all AMI visits, AMI visits not brought by an ambulance and the definitive AMI visits during which acetylsalicylic acid was not administered were 4.6 h, 4.5 h and 3.6 h, respectively (Figure 4).…”