Evaluating reasons for practice variation in the management of secondary prevention measures among coronary artery disease patients.

摘要

Hyperlipidemia and hypertension are common risk factors for recurrent cardiovascular events among patients with known coronary artery disease (CAD). Because of the importance of these two conditions, national guidelines have advocated the treatment of LDL (low-density lipoprotein) cholesterol and blood pressure (BP) to specific levels. Despite these recommendations, concordance with guideline recommendations for LDL cholesterol and blood pressure remains inadequate. The objectives of this study were (1) to determine concordance rates with LDL cholesterol and BP recommendations among patients with CAD; and (2) to identify patient factors, processes of care and structures of care associated with guideline concordance.; This was a cross sectional study of veterans with CAD from 8 VA facilities. The outcomes were concordance with LDL guideline recommendations (LDL 100 mg/dl), BP recommendations (140/90 mm Hg) and the combined outcome (both LDL 100 mg/dl and BP 140/90 mm Hg). Cumulative logit and hierarchical logistic regression analyses were performed to identify patient factors, processes of care and structures of care independently associated with guideline concordance.; Of the 14,114 veterans with CAD, 55.7% and 71.5% had hyperlipidemia and hypertension, respectively and 41.6% had both conditions. Guideline concordance for the LDL, BP and the combined outcomes were 38.9%, 53.4%, and 33.5%, respectively. In multivariable analyses, patient factors including older age and the presence of vascular disease were associated with worse guideline concordance. In contrast, diabetes was associated with better guideline concordance. Several of the process of care variables, including cardiology clinic visit, higher number of outpatient visits, higher number of prescribed medications, and a recent cardiac hospitalization were all associated with better guideline concordance. For structures of care, having on-site cardiology was associated with a trend towards better guideline concordance.; Guideline concordance with secondary prevention measures as assessed more globally based on both LDL and BP remains suboptimal. Patients at high-risk for not meeting guideline recommendations for both LDL cholesterol and BP can be easily recognized based on the factors identified in the study. Furthermore, the findings regarding processes of care can be used to redesign and improve outpatient management of secondary prevention care to increase the proportion of CAD patients meeting guideline recommendations.