Background: Ticagrelor is a P2Y12 inhibitor with better cardiovascular outcomes than clopidogrel in clinical trials for acute coronary syndromes. However, the adoption of ticagrelor into clinical practice has been understudied. Therefore, we evaluated: 1) temporal trends in ticagrelor use, 2) factors associated with its use, and 3) hospital variation in its adoption and clinical outcomes. Methods: We conducted a population-based cohort study using administrative claims data in Ontario, Canada between 4/2014 and 3/2018. We identified individuals >65 years of age who were admitted for myocardial infarction (MI) or unstable angina (UA) and filled a prescription for ticagrelor or clopidogrel at or within 7 days of discharge. We categorized hospitals into quartiles based on ticagrelor utilization rates. The primary composite outcome was 1-year death or hospitalization for MI/UA, and 1-year bleeding hospitalization was a secondary outcome. Outcomes were evaluated using a Cox proportional hazards model to compare high vs. low utilization groups. Further, we quantified the between-hospital variability of ticagrelor utilization using multi-level logistic regression analysis, expressed as median odds ratios (MOR). Results: Among 23 962 patients in our cohort, 42.5% were prescribed ticagrelor ≤7 days post-hospital discharge. Ticagrelor utilization increased from 32.6% in 2014 to 51.8% in 2017. Hospitals at the lowest quartile of ticagrelor utilization (<8.8%) had a higher hazard of the primary outcome (adjusted hazard ratio: 1.27 95%CI: 1.11-1.46, p<0.001) compared with high ticagrelor utilization hospitals (>40%). No significant difference in bleeding hospitalization across hospital quartiles was observed. Some factors associated with higher ticagrelor use were cardiologist as most responsible physician during index hospitalization and urban hospital. After adjusting for patient-, prescriber- and hospital-level characteristics, substantial variation remained between hospitals in the likelihood of patients receiving ticagrelor at discharge (MOR: 2.54). Conclusion: Increasing trends of ticagrelor utilization were observed. Ticagrelor utilization rates varied across hospitals, and hospitals with higher ticagrelor adoption were associated with better clinical outcomes.