Practice Innovation And Clinical Excellence Research Articles

Overview of Coronary Heart Disease Risk Initiatives in South Asia.

Cardiovascular disease (CVD) is now the leading cause of morbidity and mortality worldwide. Industrialization and economic growth have led to an unprecedented increment in the burden of CVD and their risk factors in less industrialized regions of the world. While there are abundant data on CVD and their risk factors from longitudinal cohort studies done in the West, good-quality data from South Asia are lacking. Several multi-institutional, observational, prospective registries, and epidemiologic cohorts in South Asia have been established to systematically evaluate the burden of CVD and their risk factors. The PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP), the Kerala Acute Coronary Syndrome (ACS), and Trivandrum Heart Failure registries have focused on secondary prevention of CVD and performance measurement in both outpatient and inpatient settings, respectively. The Prospective Urban and Rural Epidemiology (PURE), Centre for Cardiometabolic Risk Reduction in South Asia (CARRS), and other epidemiologic and genetic studies have focused on primary prevention of CVD and evaluated variables such as environment, smoking, physical activity, health systems, food and nutrition policy, dietary consumption patterns, socioeconomic factors, and healthy neighborhoods. The international cardiovascular community has been responsive to a burgeoning cardiovascular disease burden in South Asia. Several collaborations have formed between the West (North America in particular) and South Asia to catalyze evidence-based and data-driven changes in the federal health policy in this part of the world to promote cardiovascular health and mitigate cardiovascular risk.

Factors associated with rhythm control treatment decisions in patients with atrial fibrillation—Insights from the NCDR PINNACLE registry

Decisions to use rhythm control in atrial fibrillation (AF) should generally be dictated by patient factors, such as quality of life, heart failure, and other comorbidities. Whether or not other factors affect decisions about the use of rhythm control, and catheter ablation in particular, is unknown. A cohort of all patients diagnosed with nonvalvular AF were identified from the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence (PINNACLE) AF registry of US outpatient cardiology practices during the study period from May 1, 2008, to December 31, 2014. Overall and practice-specific rates of rhythm control (cardioversion, antiarrhythmic drug therapy, or catheter ablation) were assessed. We assessed patient and practice factors associated with rhythm control and determined the relative contribution of patient, practice, and unmeasured practice factors with its use. Among 511,958 PINNACLE AF patients, 22.3% were treated with rhythm control and 2.9% underwent catheter ablation. Significant practice variation in rhythm control was present (median rate of rhythm control across practices 22.8%, range 0.2%-62.9%). Significant patient factors associated with rhythm control therapy included white (vs nonwhite) race (odds ratio [OR] 2.43, P<.001), private (vs nonprivate) insurance (OR 1.04, P<.001), and whether a patient was seen by an electrophysiologist (OR 1.77, P<.001). In an analysis of the relative contribution of patient, practice, and unmeasured practice factors with rhythm control, the contribution of unmeasured practice factors (95% range OR 0.29-3.44) exceeded that of either patient (95% range OR 0.46-2.30) or practice (95% range OR 0.15-2.77) factors. One in 5 AF patients in the PINNACLE registry received rhythm control, and 1 in 50 received catheter ablation, suggesting that rhythm control may be underused. A variety of measured and unmeasured practice factors unrelated to patient characteristics play a disproportionate role in the use of rhythm control treatment decisions. Understanding the drivers of these decisions may identify inappropriate treatment variation and better inform optimal use of these therapies.

Implications of the LEGACY trial on US Atrial Fibrillation Patients: An NCDR Research to Practice (R2P) Project

The Long-term Effect of Goal Directed Weight Management in an Atrial Fibrillation Cohort: A Long-term Follow-up Study (LEGACY) demonstrated that weight reduction in a cohort of Australian patients with atrial fibrillation (AF) resulted in a reduction in AF burden and improvement in AF symptom severity. The applicability of LEGACY in US cardiovascular practice is not known. A cohort of patients with AF from the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence (PINNACLE) registry of US cardiovascular ambulatory care practices was created. The proportion of PINNACLE AF patients meeting enrollment criteria for LEGACY was assessed. Differences between these patients and LEGACY trial patients were qualitatively compared. Treatment for AF among LEGACY eligible and noneligible patients was compared. Among 349,999 US patients with AF from 179 cardiovascular practices in the PINNACLE registry, 197,255 (56.4%) met enrollment criteria for LEGACY. LEGACY-eligible PINNACLE AF had significantly lower rates of tobacco and alcohol abuse than the LEGACY trial population. There were significant differences in drug therapy comparing LEGACY eligible and LEGACY noneligible PINNACLE AF patients. In this cohort of patients in ambulatory practice in the United States with AF, over 1/2 were potential candidates for a weight management program. Differences between patients in practice and those enrolled in the trial could influence the success and impact of the LEGACY weight management intervention. Our study identifies a potential opportunity to improve AF morbidity and costs to the health care system in the United States by implementing a structured weight reduction program, such as that described in LEGACY.

The prevalence and management of angina among patients with chronic coronary artery disease across US outpatient cardiology practices: insights from the Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) study

Although eliminating angina is a primary goal in treating patients with chronic coronary artery disease (CAD), few contemporary data quantify prevalence and severity of angina across US cardiology practices. The authors hypothesized that angina among outpatients with CAD managed by US cardiologists is low and its prevalence varies by site. Among 25 US outpatient cardiology clinics enrolled in the American College of Cardiology Practice Innovation and Clinical Excellence (PINNACLE) registry, we prospectively recruited a consecutive sample of patients with chronic CAD over a 1- to 2-week period at each site between April 2013 and July 2015, irrespective of the reason for their appointment. Eligible patients had documented history of CAD (prior acute coronary syndrome, prior coronary revascularization procedure, or diagnosis of stable angina) and ≥1 prior office visit at the practice site. Angina was assessed directly from patients using the Seattle Angina Questionnaire Angina Frequency score. Among 1257 patients from 25 sites, 7.6% (n = 96) reported daily/weekly, 25.1% (n = 315) monthly, and 67.3% (n = 846) no angina. The proportion of patients with daily/weekly angina at each site ranged from 2.0% to 24.0%, but just over half (56.3%) were on ≥2 antianginal medications, with wide variability across sites (0%-100%). One-third of outpatients with chronic CAD managed by cardiologists report having angina in the prior month, and 7.6% have frequent symptoms. Among those with frequent angina, just over half were on ≥2 antianginal medications, with wide variability across sites. These findings suggest an opportunity to improve symptom control.

American College of Cardiology (ACC)’s PINNACLE India Quality Improvement Program (PIQIP)—Inception, progress and future direction: A report from the PIQIP Investigators

Cardiovascular diseases have surpassed infectious disorders to become the leading cause of morbidity and mortality in India.1 A national-level registry comprehensively documenting the current-day prevalence of cardiovascular risk factors and disease burden among patients seeking care in the outpatient setting in India is currently non-existent. With a burgeoning urban population, the cardiovascular disease burden in India is set to skyrocket, with an estimated 18 million productive years of life lost by 2030.2 While there are limited quality improvement registries in India, for example, the Kerala acute coronary syndrome and Trivandrum heart failure registries, their focus is on in-patient care quality improvement, while the vast majority of patients with cardiovascular diseases worldwide, including India, interact with the health care system in the outpatient setting.3,4 Recognizing this unmet need, the American College of Cardiology partnered with local stakeholders in India to establish India's first outpatient cardiovascular disease performance measurement initiative in 2011, the PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP).5 This manuscript discusses the inception of the PIQIP registry, the progress it has made and challenges thus far, and its future direction and the promise it holds for cardiovascular care quality improvement in India.

Aspirin Instead of Oral Anticoagulant Prescription in Atrial Fibrillation Patients at Risk for Stroke

BackgroundOral anticoagulation (OAC), rather than aspirin, is recommended in patients with atrial fibrillation (AF) at moderate to high risk of stroke. ObjectivesThis study sought to examine patient and practice-level factors associated with prescription of aspirin alone compared with OAC in AF patients at intermediate to high stroke risk in real-world cardiology practices. MethodsThe authors identified 2 cohorts of outpatients with AF and intermediate to high thromboembolic risk (CHADS2 score ≥2 and CHA2DS2-VASc ≥2) enrolled in the American College of Cardiology PINNACLE (Practice Innovation and Clinical Excellence) registry between 2008 and 2012. Using hierarchical modified Poisson regression models adjusted for patient and practice characteristics, the authors examined the prevalence and predictors of aspirin alone versus OAC prescription in AF patients at risk for stroke. ResultsOf 210,380 identified patients with CHADS2 score ≥2 on antithrombotic therapy, 80,371 (38.2%) were treated with aspirin alone, and 130,009 (61.8%) were treated with warfarin or non-vitamin K antagonist OACs. In the cohort of 294,642 patients with CHA2DS2-VASc ≥2, 118,398 (40.2%) were treated with aspirin alone, and 176,244 (59.8%) were treated with warfarin or non-vitamin K antagonist OACs. After multivariable adjustment, hypertension, dyslipidemia, coronary artery disease, prior myocardial infarction, unstable and stable angina, recent coronary artery bypass graft, and peripheral arterial disease were associated with prescription of aspirin only, whereas male sex, higher body mass index, prior stroke/transient ischemic attack, prior systemic embolism, and congestive heart failure were associated with more frequent prescription of OAC. ConclusionsIn a large, real-world cardiac outpatient population of AF patients with a moderate to high risk of stroke, more than 1 in 3 were treated with aspirin alone without OAC. Specific patient characteristics predicted prescription of aspirin therapy over OAC.

Gender disparities in cardiovascular care access and delivery in India: Insights from the American College of Cardiology's PINNACLE India Quality Improvement Program (PIQIP)

BackgroundLimited data are available to assess whether access to and quality of cardiovascular disease (CVD) care are comparable among men and women in India. We analyzed data from the American College of Cardiology's PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP) to evaluate gender disparities in CVD care delivery. Methods and resultsBetween 2011 and 2015, we collected data on performance measures for patients with coronary artery disease (CAD) (n=14,010), heart failure (HF) (n=11,965) and atrial fibrillation (AF) (n=496) in PIQIP, among 17 participating practices.The total number of women was 31,796 (32.0%). Women had fewer total encounters compared to men during the study interval (mean number of encounters=2.59 vs. 2.82 for women and men, respectively, p≤0.001). Women were significantly younger (48.9years vs. 51.5years, p≤0.01), but had a higher co-morbidity burden compared to men — hypertension (62.0% vs. 45.6%, p≤0.01), diabetes (39.4% vs. 35%, p≤0.01), and hyperlipidemia (3.7% vs. 3.1%, p=0.19). On the contrary, the guideline-directed medication prescriptions were strikingly lower in women with CAD compared to men — aspirin (38% vs. 50.4%, p≤0.001), aspirin or thienopyridine combination (46.9% vs. 57.2%, p≤0.001), and beta-blockers (36.8% vs. 47.8%, p≤0.001). Similarly, among women with ejection fraction ≤40%, the use of guideline-directed medical therapy was significantly lower compared to men for beta-blockers (30.8% vs. 37.0%, p≤0.001), angiotensin-converting enzyme inhibitors (ACE-i) or angiotensin receptor blockers (ARBs) (29.3% vs. 34.9%, p≤0.001), and beta-blockers/ACE-i or ARBs (24.6% vs. 31.0%, p≤0.001). Among patients with atrial fibrillation and CHADS2 score≥2, more women were on oral anticoagulation (19.6% vs. 14.6%, p=0.34), although this was not significantly different, and the overall number of patients with atrial fibrillation was low. ConclusionsDespite a significantly higher co-morbidity burden in women, we found fewer women receiving guideline-directed medical therapy for CVD compared with men. If such disparities are confirmed in the larger Indian population, it is important to find potential causes for, and seek solutions to narrow this gap.

GENDER DISPARITIES IN CARDIOVASCULAR CARE ACCESS AND DELIVERY IN INDIA: INSIGHTS FROM THE AMERICAN COLLEGE OF CARDIOLOGY'S PINNACLE INDIA QUALITY IMPROVEMENT PROGRAM (PIQIP)

Limited data are available to assess whether access to and quality of cardiovascular disease (CVD) care are comparable among men and women in India. We analyzed data from the American College of Cardiology's PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (

Oral Anticoagulant Therapy Prescription in Patients With Atrial Fibrillation Across the Spectrum of Stroke Risk: Insights From the NCDR PINNACLE Registry.

Patients with atrial fibrillation (AF) are at a proportionally higher risk of stroke based on accumulation of well-defined risk factors. To examine the extent to which prescription of an oral anticoagulant (OAC) in US cardiology practices increases as the number of stroke risk factors increases. Cross-sectional registry study of outpatients with AF enrolled in the American College of Cardiology National Cardiovascular Data Registry's PINNACLE (Practice Innovation and Clinical Excellence) Registry between January 1, 2008, and December 30, 2012. As a measure of stroke risk, we calculated the CHADS2 score and the CHA2DS2-VASc score for all patients. Using multinomial logistic regression models adjusted for patient, physician, and practice characteristics, we examined the association between increased stroke risk score and prescription of an OAC. The primary outcome was prescription of an OAC with warfarin sodium or a non-vitamin K antagonist OAC. The study cohort comprised 429 417 outpatients with AF. Their mean (SD) age was 71.3 (12.9) years, and 55.8% were male. Prescribed treatment consisted of an OAC (192 600 [44.9%]), aspirin only (111 134 [25.9%]), aspirin plus a thienopyridine (23 454 [5.5%]), or no antithrombotic therapy (102 229 [23.8%]). Each 1-point increase in risk score was associated with increased odds of OAC prescription compared with aspirin-only prescription using the CHADS2 score (adjusted odds ratio, 1.158; 95% CI, 1.144-1.172; P < .001) and the CHA2DS2-VASc score (adjusted odds ratio, 1.163; 95% CI, 1.157-1.169; P < .001). Overall, OAC prescription prevalence did not exceed 50% even in higher-risk patients with a CHADS2 score exceeding 3 or a CHA2DS2-VASc score exceeding 4. In a large quality improvement registry of outpatients with AF, prescription of OAC therapy increased with a higher CHADS2 score and CHA2DS2-VASc score. However, a plateau of OAC prescription was observed, with less than half of high-risk patients receiving an OAC prescription.

Guideline-Directed Medication Use in Patients With Heart Failure With Reduced Ejection Fraction in India: American College of Cardiology's PINNACLE India Quality Improvement Program.

Little is known about the use of guideline-directed medical therapy (GDMT) in outpatients with heart failure with reduced left ventricular ejection fraction (HFrEF; ≤40%) in India. Our objective was to understand the use of GDMT in outpatients with HFrEF in India. The Practice Innovation And Clinical Excellence (PINNACLE) India Quality Improvement Program (PIQIP) is a registry for cardiovascular quality improvement in India supported by the American College of Cardiology Foundation. Between January 2008 and September 2014, we evaluated documentation of use of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) and β-blockers, or both, among outpatients with HFrEF seeking care in 10 centers enrolled in the PIQIP registry. Among 75 639 patients in the PIQIP registry, 34 995 had EF reported, and 15 870 had an EF ≤40%. The mean age was 56 years; 23% were female. Hypertension, diabetes, coronary artery disease, and myocardial infarction were present in 37%, 23%, 27%, and 17%, respectively. Use of ACEIs/ARBs, β-blockers, and both were documented in 33.5%, 34.9%, and 29.6% of patients, respectively. The documentation of GDMT was higher in men, in patients age ≥65 years, and in those with presence of hypertension, diabetes, or coronary artery disease. Documentation of GDMT gradually increased over the study period. Among patients enrolled in the PIQIP registry, about two-thirds of patients with EF ≤40% did not have documented receipt of GDMT. This study is an initial step toward improving adherence to GDMT in India and highlights the feasibility of examining quality of care in HFrEF in a resource-limited setting.

Gender disparities in cardiovascular care access and delivery in India: Insights from the American College of Cardiology's PINNACLE India Quality Improvement Program (PIQIP)

Limited data are available to assess whether access to and quality of cardiovascular disease (CVD) care are comparable among men and women in India. We analyzed data from the American College of Cardiology's PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (

Abstract 12446: Frequency and Practice Level Variation in Statin Use Among Patients With Diabetes: Insights From the NCDR® PINNACLE Registry

Background: Statins reduce major adverse cardiovascular events and mortality among patients with diabetes and routine use is endorsed by clinical practice guidelines. However, national trends and practice level variation in statin use are not known. Methods: From the American College of Cardiology’s Practice Innovation and Clinical Excellence (PINNACLE) registry, we identified 256,701 patients with diabetes 40-75 years of age from 187 practices with at least 30 diabetic patients between May 1, 2008 and September 31, 2014. Among patients without contraindication to statin therapy, we calculated the percentage of patients receiving statin therapy at each practice. We then examined variation in statin use across practices using multivariable hierarchical regression to determine median rate ratio (MRR), which quantifies the likelihood that 2 randomly chosen practices would differ in treating an identical patient. Results: Overall, 141,900 (55%) diabetic patients were on statins. Those prescribed statins were more likely to be men, of white race, have coexisting dyslipidemia or hypertension, be on non-statin lipid lowering medications and have lower LDL-C levels (91 vs. 103 mg/dL, P&lt;0.001 for all). The median practice level use of statin was 57% (IQR, 48-63%), which remained similar throughout the study period. The adjusted MRR for statin use was 1.62 (95% CI: 1.57-1.67), indicating 62% differences in likelihood of statin treatment between 2 identical patients at 2 random practices (Figure). Conclusion: In a national outpatient registry, just over half of patients with diabetes 40-75 years old were treated with statins, with wide variation across cardiology practices. These results suggest that quality improvement initiatives are needed to support guideline recommended use of statins among patients with diabetes.

Practice Variation in Triple Therapy for Patients With Both Atrial Fibrillation and Coronary Artery Disease: Insights From the ACC's National Cardiovascular Data Registry.

The aim of this study was to test the hypothesis that in the United States substantial practice variation exists in triple therapy prescribing practices, unrelated to measured patient factors. Recent data have shown that the risk of bleeding on dual antiplatelet therapy and oral anticoagulation ("tripletherapy") is high, although the optimal strategy for patients with atrial fibrillation and coronary artery disease remains unclear. Using the PINNACLE (National Practice Innovation and Clinical Excellence) registry, we identified 79,875 unique patients with both atrial fibrillation/atrial flutter and myocardial infarction and/or coronary stenting within 12months. Using triple therapy as a binary outcome variable, we created a mixed-effects logistic regression model with patient factors as fixed effects and practice site as a random effect. Patient factors included age, sex, diabetes, congestive heart failure, hypertension, peripheral arterial disease, prior stroke or transient ischemic attack, history of systemic embolization, and dyslipidemia. The model was assessed with a median odds ratio to assess practice variation after adjustment for patient factors. After adjustment for patient factors, significant practice variation was suggested by a median odds ratio of 2.78 (95% confidence interval: 2.33 to 3.23). In particular, this suggests that 2 randomly selected practices would differ in their likelihood of prescribing triple therapy for an identical patient by a factor of nearly3. In the United States, there is substantial practice variation in prescribing triple therapy to eligible patients even after adjustment for patient clinical characteristics. These results suggest that opportunities exist toimprove the quality of careofthis sizable population.

Oral Anticoagulant Prescription in Patients With Atrial Fibrillation and a Low Risk of Thromboembolism: Insights From the NCDR PINNACLE Registry.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, with an estimated 1 in 4 lifetime risk in those older than 40 years of age and a projected increase in prevalence to approximately 5.6 million affected individuals in the United States by the year 2050 (1,2). In patients with AF at higher risk for thromboembolism, anticoagulation with warfarin (a vitamin K antagonist) or the newer novel anticoagulants reduces morbidity and mortality (3–6). Because oral anticoagulant use carries a risk of bleeding, including potentially fatal intracranial hemorrhage, anticoagulant treatment is not recommended in AF patients at a particularly low risk for stroke. Specifically, previous AF guidelines recommend against the use of oral anticoagulation in patients under 60 years of age without heart disease or other known risk factors for thromboembolism (7), and more recently updated guidelines do not recommend oral anticoagulation in AF patients without any established risk factor for stroke (8). Although it is well known that appropriate oral anticoagulant prescription in AF patients at risk for stroke outside clinical trial settings falls short of guideline-based expectations (9–12), it is unknown whether young and healthy AF patients with the lowest stroke risk are being treated with oral anticoagulation that may increase bleeding risk without a commensurate reduction in stroke risk. To our knowledge, a real-world evaluation of guideline adhering practice patterns of anticoagulation prescription in AF patients with the lowest stroke risk has never been performed. We evaluated the prevalence of oral anticoagulant prescription by cardiovascular specialists in a cohort of outpatients using data from the National Cardiovascular Data Registry (NCDR)’s Practice Innovation and Clinical Excellence (PINNACLE) Registry®. Use of this prospective national registry of cardiovascular care in the United States provides a unique opportunity to examine patterns of oral anticoagulant treatment in routine practice among outpatients as well as clinical predictors of this practice.

Inappropriate use of aspirin for primary prevention

Finer points Current guidelines vary slightly in their exact recommendations for aspirin use in the primary prevention setting. However, most consider aspirin appropriate for primary prevention when the 10-year CV risk is 6% or more. To determine the frequency of inappropriate use of aspirin in the primary prevention setting, researchers examined a cohort of patients receiving aspirin for primary prevention who were enrolled in the American College of Cardiology’s National Cardiovascular Disease Registry’s Practice Innovation and Clinical Excellence (PINNACLE) registry. Inappropriate aspirin use was characterized as use in patients with a 10-year CV risk of less than 6% by the Framingham CV risk assessment tool. A total of 68,808 patients were identi ed from 119 medical practices across the United States from January 2008 to June 2013. Of the 68,808 patients reviewed, 7,972 (11.6%) were classi ed as inappropriately receiving aspirin therapy for primary prevention. The mean 10-year CV risk in the inappropriate-use group was 4% compared with 24.5% in the appropriate-use group (P < 0.001). An assessment of individual practices revealed substantial variation for inappropriate aspirin use across practices, ranging from 0% to 71.8% (median 10.1%). However, only modest regional variations were observed in the northeast, midwest, south, and west.

Implications of the 2013 ACC/AHA Cholesterol Guidelines for Adults in Contemporary Cardiovascular Practice: Insights From the NCDR PINNACLE Registry

BackgroundIn a significant update, the 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines recommend fixed-dose statin therapy for those at risk and do not recommend nonstatin therapies or treatment to target low-density lipoprotein cholesterol (LDL-C) levels, limiting the need for repeated LDL-C testing. ObjectivesThe goal of this study was to examine the impact of the 2013 ACC/AHA cholesterol guidelines on current U.S. cardiovascular practice. MethodsUsing the NCDR PINNACLE (National Cardiovascular Data Registry Practice Innovation and Clinical Excellence) registry data from 2008 to 2012, we assessed current practice patterns as a function of the 2013 cholesterol guidelines. Lipid-lowering therapies and LDL-C testing patterns by patient risk group (atherosclerotic cardiovascular disease [ASCVD], diabetes, LDL-C ≥190 mg/dl, or an estimated 10-year ASCVD risk ≥7.5%) were described. ResultsAmong a cohort of 1,174,545 patients, 1,129,205 (96.1%) were statin-eligible (91.2% ASCVD, 6.6% diabetes, 0.3% off-treatment LDL-C ≥190 mg/dl, 1.9% estimated 10-year ASCVD risk ≥7.5%). There were 377,311 patients (32.4%) not receiving statin therapy and 259,143 (22.6%) receiving nonstatin therapies. During the study period, 20.8% of patients had 2 or more LDL-C assessments, and 7.0% had more than 4. ConclusionsIn U.S. cardiovascular practices, 32.4% of statin-eligible patients, as defined by the 2013 ACC/AHA cholesterol guidelines, were not currently receiving statins. In addition, 22.6% were receiving nonstatin lipid-lowering therapies and 20.8% had repeated LDL-C testing. Achieving concordance with the new cholesterol guidelines in patients treated in U.S. cardiovascular practices would result in significant increases in statin use, as well as significant reductions in nonstatin therapies and laboratory testing.

Guideline recommended medication use among systolic heart failure patients in India: Insights from the American college of cardiology practice innovation and clinical excellence (PINNACLE)® India Registry

Guideline recommended medication use among systolic heart failure patients in India: Insights from the American college of cardiology practice innovation and clinical excellence (PINNACLE)® India Registry

Abstract 15: Frequency and Predictors of Inappropriate Aspirin Prescribing for Primary Prevention of Cardiovascular Disease: Insights from the NCDR® PINNACLE Registry.

Background: Aspirin use is recommended in patients with cardiovascular disease (CVD) for secondary prevention. However, among men and women without CVD and low 10 year coronary heart disease (CHD) risk, aspirin use for primary prevention has not been shown to reduce CVD death or all-cause death. In low risk patients, the risks of gastrointestinal bleeding and hemorrhagic strokes associated with aspirin use outweigh any potential atheroprotective benefit. As per the American Heart Association (AHA) guidelines on Primary Prevention of CVD and Stroke in 2002 and U.S. Preventive Services Task Force (USPSTF) recommendations from 2009, use of aspirin is considered appropriate in patients with &gt; 6% 10 year Framingham CHD risk and inappropriate in patients with 10 year risk &lt; 6%. We studied the frequency and predictors of inappropriate aspirin prescribing for primary prevention in a large national registry. Methods: Within the NCDR Practice Innovation and Clinical Excellence (PINNACLE) Registry, we identified 267,957 patients without CVD (coronary heart disease, peripheral arterial disease or ischemic stroke) or atrial fibrillation receiving aspirin for primary prevention. Of these, Framingham Risk Score (FRS) could be calculated in 68,808 patients. We assessed the frequency of inappropriate aspirin prescribing for primary prevention (aspirin prescribing in those with FRS &lt;6%). Using hierarchical regression models, we also assessed the extent of practice-level variation using the median rate ratio (MRR). MRR is interpreted as the likelihood that 2 random practices would differ in treating identical patients with aspirin inappropriately. Results: Inappropriate aspirin prescribing rate was 32.8 % (22601/68808) in the overall cohort. Mean FRS in the inappropriate aspirin group was 3.6 versus 16.2 in the appropriate group (p&lt;0.001). Significant variation was noted between practices in the Northeast, Midwest, South and West with inappropriate aspirin prescribing rates ranging from 31.5% to 34.4% (p&lt;0.0001). There was practice-level variation in inappropriate prescribing (range 17.9-52.4%, median rate 33.5%, interquartile range 28.6-37.7%) for practices; adjusted MRR 1.19 [95% CI 1.14 to 1.23]. Results remained consistent after excluding 14,097 patients with diabetes (inappropriate aspirin use rate = 38.2%, median rate 37.6%, interquartile range 32.5-43.8%; adjusted MRR 1.17 [95% CI 1.13- 1.21]). Conclusion: Inappropriate aspirin prescribing occurs in approximately one third of patients receiving aspirin for primary prevention. There is modest but significant practice-level variation. Our findings identify opportunities to improve evidence-based aspirin prescribing in primary CVD prevention.

Variations in Coronary Artery Disease Secondary Prevention Prescriptions Among Outpatient Cardiology Practices: Insights From the NCDR (National Cardiovascular Data Registry)

This study assessed practice variations in secondary prevention medication prescriptions among coronary artery disease (CAD) patients treated in outpatient practices participating in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry.Among patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics.Using data from NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients, between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics.Among 156,145 CAD patients in 58 practices, 103,830 (66.5%) patients were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% confidence interval: 1.20 to 1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients.Among a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice.

Cardiovascular Care Facts: A Report From the National Cardiovascular Data Registry: 2011

The aim of this report was to characterize the patients, participating centers, and measures of quality of care and outcomes for 5 NCDR (National Cardiovascular Data Registry) programs: 1) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-GWTG (Get With The Guidelines) for acute coronary syndromes; 2) CathPCI Registry for coronary angiography and percutaneous coronary intervention; 3) CARE (Carotid Artery Revascularization and Endarterectomy) Registry for carotid revascularization; 4) ICD Registry for implantable cardioverter defibrillators; and the 5) PINNACLE (Practice INNovation And CLinical Excellence) Registry for outpatients with cardiovascular disease (CVD). CVD is a leading cause of death and disability in the United States. The quality of care for patients with CVD is suboptimal. National registry programs, such as NCDR, permit assessments of the quality of care and outcomes for broad populations of patients with CVD. For the year 2011, we assessed for each of the 5 NCDR programs: 1) demographic and clinical characteristics of enrolled patients; 2) key characteristics of participating centers; 3) measures of processes of care; and 4) patient outcomes. For selected variables, we assessed trends over time. In 2011 ACTION Registry-GWTG enrolled 119,967 patients in 567 hospitals; CathPCI enrolled 632,557 patients in 1,337 hospitals; CARE enrolled 4,934 patients in 130 hospitals; ICD enrolled 139,991 patients in 1,435 hospitals; and PINNACLE enrolled 249,198 patients (1,436,328 individual encounters) in 74 practices (1,222 individual providers). Data on performance metrics and outcomes, in some cases risk-adjusted with validated NCDR models, are presented. The NCDR provides a unique opportunity to understand the characteristics of large populations of patients with CVD, the centers that provide their care, quality of care provided, and important patient outcomes.