Practice variation in triple therapy for patients with both atrial fibrillation and coronary artery disease insights from the ACC's National Cardiovascular Data Registry

Abstract

Objectives The aim of this study was to test the hypothesis that in the United States substantial practice variation exists in triple therapy prescribing practices, unrelated to measured patient factors. Background Recent data have shown that the risk of bleeding on dual antiplatelet therapy and oral anticoagulation ("triple therapy") is high, although the optimal strategy for patients with atrial fibrillation and coronary artery disease remains unclear. Methods Using the PINNACLE (National Practice Innovation and Clinical Excellence) registry, we identified 79,875 unique patients with both atrial fibrillation/atrial flutter and myocardial infarction and/or coronary stenting within 12 months. Using triple therapy as a binary outcome variable, we created a mixed-effects logistic regression model with patient factors as fixed effects and practice site as a random effect. Patient factors included age, sex, diabetes, congestive heart failure, hypertension, peripheral arterial disease, prior stroke or transient ischemic attack, history of systemic embolization, and dyslipidemia. The model was assessed with a median odds ratio to assess practice variation after adjustment for patient factors. Results After adjustment for patient factors, significant practice variation was suggested by a median odds ratio of 2.78 (95% confidence interval: 2.33 to 3.23). In particular, this suggests that 2 randomly selected practices would differ in their likelihood of prescribing triple therapy for an identical patient by a factor of nearly 3. Conclusions In the United States, there is substantial practice variation in prescribing triple therapy to eligible patients even after adjustment for patient clinical characteristics. These results suggest that opportunities exist to improve the quality of care of this sizable population.