Abstract
BackgroundGuidelines recommend both acetylsalicylic acid and ticagrelor following acute coronary syndrome (ACS), but appropriate prescription practices lag. We analyzed the impact of government medication approval, national guideline updates, and publicly funded drug coverage plans on P2Y12 inhibitor utilization.MethodsAccessing provincial databases, we obtained data for elderly ACS patients in Ontario, Canada, between 2008 and 2018. Using interrupted-time series with descriptive statistics and segmented regression analysis, we evaluated types of P2Y12 inhibitors prescribed at discharge and changes to their utilization in patients managed with percutaneous intervention (PCI), coronary artery bypass grafting (CABG) or medically, following national antiplatelet therapy guidelines (by the Canadian Cardiovascular Society), ticagrelor’s national approval by Health Canada, and ticagrelor’s coverage by a publicly funded medication plan.ResultsWe included 114,142 patients (49.4%-PCI; mean age 75.71±6.94 and 62.3% male and 7.7%-CABG; mean age 74.11±5.63 and 73.5% male).Among PCI patients, clopidogrel utilization declined monthly after 2010 national guidelines were published (p<0.0001) and within the first month after ticagrelor’s national approval by Health Canada (p=0.03). Among PCI patients, ticagrelor utilization increased within the first month (p<0.0001) and continued increasing monthly (p<0.0001) after its coverage by a publicly funded medication plan. Among PCI patients, clopidogrel utilization declined within the first month (p=0.003) and ticagrelor utilization increased monthly (p=0.05) after 2012 CCS guidelines.Among CABG patients, ticagrelor’s coverage was associated with a monthly increase in its utilization (p<0.0001).ConclusionNational guideline updates and drug coverage by a publicly funded medication plan significantly improved P2Y12 inhibitor utilization. Barriers to appropriate antiplatelet therapy in the surgical population must be explored.
Highlights
Based on large, multi-center randomized controlled trials (RCTs), guidelines recommend dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor for 12 months after an acute coronary syndrome (ACS), regardless of management strategy: medical management, percutaneous intervention (PCI), or coronary artery bypass grafting (CABG) [1,2,3,4,5,6,7,8,9,10]
Using the knowledge-to-action framework, we discovered that policy changes—such as coverage by a publicly funded model—were essential in uptake of evidence
Managed patients were more likely to have undergone previous interventions (PCI and/or CABG) and had more comorbidities with a higher proportion presenting with congestive heart failure (CHF), chronic obstructive pulmonary obstruction (COPD), cerebrovascular disease (CVD), and peripheral vascular disease (PVD)
Summary
Multi-center randomized controlled trials (RCTs), guidelines recommend dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor for 12 months after an acute coronary syndrome (ACS), regardless of management strategy: medical management, percutaneous intervention (PCI), or coronary artery bypass grafting (CABG) [1,2,3,4,5,6,7,8,9,10]. A focused update was released in 2013, exclusively recommending ticagrelor and ASA for all ACS patients [10, 11]. Despite these recommendations and available evidence, appropriate DAPT use remains variable. In a cohort of patients with ACS, CABG was an independent predictor for DAPT underutilization (odds ratio [OR] 0.09, 95%CI 0.05–0.14) [14,15,16]. Guidelines recommend both acetylsalicylic acid and ticagrelor following acute coronary syndrome (ACS), but appropriate prescription practices lag. We analyzed the impact of government medication approval, national guideline updates, and publicly funded drug coverage plans on P2Y12 inhibitor utilization
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
