省级和国家级实施策略对老年人急性冠脉综合征中 P2Y12 抑制剂使用的影响：2008 年至 2018 年的中断时间序列分析。
Impact of provincial and national implementation strategies on P2Y12 inhibitor utilization for acute coronary syndrome in the elderly: an interrupted time series analysis from 2008 to 2018.
机构信息
Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
出版信息
Implement Sci. 2021 Apr 21;16(1):42. doi: 10.1186/s13012-021-01117-z.
BACKGROUND
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.
METHODS
Accessing 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.
RESULTS
We 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).
CONCLUSION
National 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.
背景
指南建议在急性冠脉综合征（ACS）后使用乙酰水杨酸和替格瑞洛，但适当的处方实践仍存在滞后。我们分析了政府药物批准、国家指南更新以及公共资助药物覆盖计划对 P2Y12 抑制剂使用的影响。
方法
我们访问了安大略省的省级数据库，获取了 2008 年至 2018 年期间加拿大老年 ACS 患者的数据。使用描述性统计和分段回归分析，我们评估了出院时开具的 P2Y12 抑制剂类型以及在遵循国家抗血小板治疗指南（加拿大心血管学会）、加拿大卫生部批准替格瑞洛以及公共资助药物计划覆盖替格瑞洛后，经皮介入治疗（PCI）、冠状动脉旁路移植术（CABG）或药物治疗的患者中 P2Y12 抑制剂使用情况的变化。
结果
我们纳入了 114142 名患者（49.4%-PCI；平均年龄 75.71±6.94 岁，62.3%为男性；7.7%-CABG；平均年龄 74.11±5.63 岁，73.5%为男性）。在 PCI 患者中，2010 年国家指南发布后，氯吡格雷的使用率每月下降（p<0.0001），并且在加拿大卫生部批准替格瑞洛后的第一个月内（p=0.03）下降。在 PCI 患者中，替格瑞洛的使用率在第一个月内增加（p<0.0001），并且在公共资助药物计划覆盖后每月继续增加（p<0.0001）。在 PCI 患者中，氯吡格雷的使用率在第一个月内下降（p=0.003），替格瑞洛的使用率在 2012 年 CCS 指南发布后每月增加（p=0.05）。在 CABG 患者中，替格瑞洛的覆盖范围与每月使用率的增加相关（p<0.0001）。
结论
国家指南更新和公共资助药物计划的药物覆盖显著改善了 P2Y12 抑制剂的使用。必须探索手术人群中适当抗血小板治疗的障碍。
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