Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia.
Safer Care Victoria, Melbourne, Victoria, Australia.
Intern Med J. 2022 Feb;52(2):249-258. doi: 10.1111/imj.15036.
P2Y inhibitor therapy is recommended for 12 months in patients hospitalised for acute myocardial infarction (AMI) unless the bleeding risk is high.
To describe real-world use of P2Y inhibitor therapy following AMI hospitalisation.
We used population-level linked hospital data to identify all patients discharged from a public hospital with a primary diagnosis of AMI between July 2011 and June 2013 in New South Wales and Victoria, Australia. We used dispensing claims to examine dispensing of a P2Y inhibitor (clopidogrel, prasugrel or ticagrelor) within 30 days of discharge and multilevel models to identify predictors of post-discharge dispensing and persistence of therapy to 1 year.
We identified 31 848 patients hospitalised for AMI, of whom 56.8% were dispensed a P2Y inhibitor within 30 days of discharge. The proportion of patients with post-discharge dispensing varied between hospitals (interquartile range: 25.0-56.5%), and significant between-hospital variation remained after adjusting for patient characteristics. Patient factors associated with the lowest likelihood of post-discharge dispensing were: having undergone coronary artery bypass grafting (odds ratio (OR): 0.17; 95% confidence intervals (CI): 0.15-0.20); having oral anticoagulants dispensed 180 days before or 30 days after discharge (OR: 0.39, 95% CI: 0.35-0.44); major bleeding (OR: 0.68, 95% CI: 0.61-0.76); or being aged ≥85 years (OR: 0.68, 95% CI: 0.62-0.75). A total of 26.8% of patients who were dispensed a P2Y inhibitor post-discharge discontinued therapy within 1 year.
Post-hospitalisation use of P2Y inhibitor therapy in AMI patients is low and varies substantially by hospital of discharge. Our findings suggest strategies addressing both health system (hospital and physician) and patient factors are needed to close this evidence-practice gap.
除非出血风险高，否则建议对因急性心肌梗死（AMI）住院的患者使用 P2Y 抑制剂治疗 12 个月。
描述 AMI 住院后 P2Y 抑制剂治疗的实际应用情况。
我们使用人群水平的医院数据，确定了 2011 年 7 月至 2013 年 6 月期间澳大利亚新南威尔士州和维多利亚州因原发性 AMI 出院的所有患者。我们使用配药记录，在出院后 30 天内检查 P2Y 抑制剂（氯吡格雷、普拉格雷或替卡格雷）的配药情况，并使用多层次模型确定出院后配药和治疗持续至 1 年的预测因素。
我们共确定了 31848 例因 AMI 住院的患者，其中 56.8%在出院后 30 天内使用了 P2Y 抑制剂。出院后配药的患者比例在医院之间有所不同（四分位距：25.0-56.5%），在调整患者特征后仍存在显著的医院间差异。与出院后配药可能性最低相关的患者因素包括：接受过冠状动脉旁路移植术（比值比（OR）：0.17；95%置信区间（CI）：0.15-0.20）；在出院前 180 天或出院后 30 天内使用口服抗凝剂（OR：0.39，95%CI：0.35-0.44）；大出血（OR：0.68，95%CI：0.61-0.76）；或年龄≥85 岁（OR：0.68，95%CI：0.62-0.75）。出院后使用 P2Y 抑制剂治疗的患者中，有 26.8%在 1 年内停止了治疗。
AMI 患者出院后使用 P2Y 抑制剂治疗的比例较低，且出院医院之间差异很大。我们的研究结果表明，需要采取针对卫生系统（医院和医生）和患者因素的策略，以缩小这一证据与实践之间的差距。
