Journal
JOURNAL OF THE AMERICAN HEART ASSOCIATION
Volume 11, Issue 13, Pages -Publisher
WILEY
DOI: 10.1161/JAHA.121.024835
Keywords
acute coronary syndrome; antiplatelet agents; hospital variation; outcomes research; quality of care; ticagrelor
Categories
Funding
- ICES - Ontario Ministry of Health
- Ministry of Long-Term Care
- Canadian Institutes of Health Research [FDN-154333]
- Eliot Phillipson Clinician-Scientist Program at the University of Toronto
- Canadian Institute of Health Research Post-Doctoral Fellowship
- Heart and Stroke Foundation, Ontario Provincial Office
- Jack Tu Chair in Cardiovascular Outcomes Research
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A study in Ontario, Canada found significant variations in ticagrelor usage rates among ACS patients, strongly associated with physician and hospital factors independent of patient characteristics.
Background Despite improved outcomes associated with ticagrelor compared with clopidogrel in acute coronary syndrome (ACS), many studies have demonstrated slow adoption of ticagrelor in the United States because of its increased cost. Less is known about how ticagrelor is adopted when there is no added cost consideration. Our objectives were to determine patterns of use of ticagrelor, hospital-level adoption of ticagrelor use, and factors associated with its use after ACS in a publicly funded health care system. Methods and Results We conducted a population-based cohort study including patients (>= 65 years) hospitalized with their first ACS from April 2014 to March 2018 in Ontario, Canada. We determined temporal trends in ticagrelor use and hospital-level adoption of its use post-ACS discharge. Using hierarchical regression models, we identified significant predictors of ticagrelor use. There were 23 962 patients with ACS (mean age 76.3 years, 59.7% men) hospitalized in 156 hospitals. Overall ticagrelor use increased from 32.6% in 2014/2015 to 51.8% in 2017/2018. There was substantial variation in ticagrelor use post-ACS across hospitals, with hospital-specific prescribing rates ranging from 0% to 83.6%. Lower odds of ticagrelor use was associated with advanced age and the presence of comorbidities. Besides patient factors, being admitted to a rurally located hospital more than halved the odds of being prescribed ticagrelor (odds ratio [OR], 0.49; 95% CI, 0.32-0.77). Being managed by a cardiologist during the index ACS hospitalization was associated with higher odds of having a ticagrelor prescription after ACS (OR, 2.80; 95% CI, 2.36-3.33). Conclusions Ticagrelor use rates varied substantially across hospitals and were strongly associated with physician and hospital factors independent of patient characteristics.
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