Smolderen Kim G, Romain Gaëlle, Cleman Jacob, Scierka Lindsey, Mena-Hurtado Carlos
Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Department of Psychiatry, Psychology Section, Yale University School of Medicine, New Haven, CT.
Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT.
Am Heart J. 2024 Apr;270:75-85. doi: 10.1016/j.ahj.2024.01.008. Epub 2024 Feb 1.
The use of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) decreases the risk of death and amputation and may decrease hospital readmissions. The variability of GDMT prescription across sites and operators and the proportionality of risk is not well understood. We aimed to study the association between variability of GDMT prescription at the site and operator level and outcomes (including 90-day readmissions and 24-month all-cause mortality and major amputation).
We examined GDMT discharge rates in PVIs performed between 2017 and 2018 using Medicare-linked Vascular Quality Initiative registry. GDMT included a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-i/ARB) if hypertensive. Quartiles (Q1-4) of GDMT rates were documented by operators and sites and variability was quantified using median odds ratios (MOR) and intraclass correlation (ICC). The association between lower GDMT rates (per 10%) by sites and operators with 90-day readmission were calculated using logistic regression, and with 24-month mortality and major amputation using parametric survival model. Models were adjusted for patient-level factors and included sites and operators nested within sites as 2 random effects.
GDMT rates for 17,147 patients across 223 sites and 1,263 operators ranged from 0% to 38% (Q1, MOR 1.43, 95%CI 1.39-1.47, P ≤ .001) to 57%-100% (Q4, MOR 1.48, 95%CI 1.44-1.51, P ≤ .001). Four percent of variance in GDMT use was explained by sites (ICC 3.9, 95%CI 2.9-5.3) and operators (ICC 4.1, 95%CI 3.1-5.4). A dose-response relationship was noted between lower GDMT rates and increased risk of 90-day readmission risk by sites (P = .021) and operators (P < .001). Lower GDMT prescription by site was associated with higher risk of 24-month mortality (HR = 1.07, 95%CI 1.02-1.13) and major amputation (HR = 1.08, 95%CI 1.01-1.15). Similar associations were found for GDMT use by provider (mortality HR = 1.05, 95%CI 1.02-1.08 and amputation HR = 1.04, 95%CI 1.00-1.08).
Both at the operator and health system level, there was significant variability in GDMT prescription following PVI, proportionally translating into risk for readmission, mortality, and major amputation. Targeted quality efforts should prioritize both operator and site levels to improve GDMT use and outcomes for patients undergoing PVI.
在接受外周血管介入治疗（PVI）的患者中使用指南指导的药物治疗（GDMT）可降低死亡和截肢风险，并可能减少医院再入院率。目前对于不同地点和操作人员之间GDMT处方的差异以及风险比例尚不清楚。我们旨在研究在地点和操作人员层面上GDMT处方的差异与结局（包括90天再入院率、24个月全因死亡率和大截肢率）之间的关联。
我们使用与医疗保险相关的血管质量改进计划登记处的数据，研究了2017年至2018年期间进行的PVI中GDMT的出院率。GDMT包括他汀类药物、抗血小板治疗，以及高血压患者使用的血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACE-i/ARB）。操作人员和地点记录了GDMT率的四分位数（Q1-4），并使用中位数优势比（MOR）和组内相关系数（ICC）对差异进行量化。使用逻辑回归计算地点和操作人员较低的GDMT率（每降低10%）与90天再入院率之间的关联，并使用参数生存模型计算与24个月死亡率和大截肢率之间的关联。模型针对患者层面的因素进行了调整，并将地点和地点内的操作人员作为两个随机效应纳入。
223个地点的1263名操作人员对17147名患者的GDMT率范围为0%至38%（Q1，MOR 1.43，95%CI 1.39-1.4７, P≤.001）至57%-100%（Q4，MOR 1.48，95%CI 1.44-1.51, P≤.001）。地点（ICC 3.9，95%CI 2.9-5.3）和操作人员（ICC 4.1，95%CI 3.1-5.4）解释了GDMT使用中4%的差异。地点和操作人员较低的GDMT率与90天再入院风险增加之间存在剂量反应关系（地点P =.021，操作人员P <.001）。地点较低的GDMT处方与24个月死亡率（HR = 1.07，95%CI 1.02-1.13）和大截肢率（HR = 1.08，95%CI 1.01-1.15）较高相关。对于操作人员使用GDMT的情况也发现了类似的关联（死亡率HR = 1.05，95%CI 1.02-1.0８；截肢率HR = 1.04，95%CI 1.00-1.08）。
在操作人员和卫生系统层面，PVI后GDMT处方均存在显著差异，这相应地转化为再入院、死亡和大截肢的风险。有针对性的质量改进工作应将操作人员和地点层面作为优先事项，以改善接受PVI患者的GDMT使用情况和结局。
