A2161 JACC April 1, 2014 Volume 63, Issue 12
Young Investigator Awards Competition Frequency and Practice Level Variation in Inappropriate and Non-Recommended Prasugrel Prescribing: Insights from the NCDR®PINNACLE Registry Oral Contributions Room 147 B Monday, March 31, 2014, 11:15 a.m.-11:30 a.m.
Session Title: Young Investigator Awards Competition: Cardiovascular Health Outcomes and Population Genetics Abstract Category: Cardiovascular Health Outcomes and Population Genetics Presentation Number: 931-07 Authors: Ravi S. Hira, Kevin Kennedy, Hani Jneid, Mahboob Alam, Sukhdeep Basra, Christie Ballantyne, Vijay Nambi, Paul Chan, Salim Virani, Baylor College of Medicine, Houston, TX, USA Background: Prasugrel is a newer P2Y12 inhibitor antiplatelet agent. Compared to clopidogrel, it significantly decreased the composite of cardiovascular death, nonfatal myocardial infarction (MI) and stroke. However, it increased major bleeding in patients with previous stroke or transient ischemic attack, and is therefore contraindicated (henceforth termed inappropriate) in them. Its use is also not recommended in patients aged > 75 years without history of diabetes or MI, where its bleeding risk likely exceeds benefit (henceforth termed non-recommended when combined with inappropriate). Methods: Within the NCDR PINNACLE Registry’s 8,007,927 patient encounters, we identified 27533 patients receiving prasugrel. We assessed frequency of inappropriate and non-recommended prasugrel prescribing since its approval in July 2009. Using hierarchical regression models, we also assessed the extent of practice-level variation using the median rate ratio (MRR), interpreted as the likelihood that 2 random practices would differ in treating identical patients with prasugrel inappropriately. Results: Inappropriate and non-recommended prasugrel prescribing rates were 13.9% (3824/27533) and 18.3% (5034/27533), respectively. There was substantial practice-level variation in inappropriate prescribing (median rate 4.4%, interquartile range 2-10%, range 0-90% for practices) with a MRR of 2.89 (95% CI 2.75 to 3.03). Significant variation was noted between practices in the Northeast, Midwest, South, and West with inappropriate prescribing rates ranging from 10.4% to 18.7% (p<0.001). There was also significant practice-level variation in non-recommended prescribing (median rate 7.7%, range 0-91.5% for practices) with a MRR of 2.50 (95% CI 2.39 to 2.62). 4248 patients (15.4%) were also receiving concomitant aspirin and warfarin with 996 (23.4%) of these receiving prasugrel when not recommended. Conclusion: Inappropriate and non-recommended prasugrel prescribing are prevalent with large practice-level and regional variations. Our findings identify opportunities to improve appropriate and evidence-driven prescribing of prasugrel.