Quality of care after acute coronary syndromes in a prospective cohort with reasons for non-prescription of recommended medications

Abstract

Background: Adherence to guidelines is associated with improved outcomes of patients with acute coronary syndrome (ACS). Clinical registries developed to assess quality of care at discharge often do not collect the reasons for non-prescription for proven efficacious preventive medication in Continental Europe. In a prospective cohort of patients hospitalized for an ACS, we aimed at measuring the rate of recommended treatment at discharge, using pre-specified quality indicators recommended in cardiologic guidelines and including systematic collection of reasons for non-prescription for preventive medications.

Methods: In a prospective cohort with 1260 patients hospitalized for ACS, we measured the rate of recommended treatment at discharge in 4 academic centers in Switzerland. Performance measures for medication at discharge were pre-specified according to guidelines, systematically collected for all patients and included in a centralized database.

Results: Six hundred and eighty eight patients(54.6%) were discharged with a main diagnosis of STEMI, 491(39%) of NSTEMI and 81(6.4%) of unstable angina. Mean age was 64 years and 21.3% were women. 94.6% were prescribed angiotensin converting enzyme inhibitors/angiotensin II receptor blockers at discharge when only considering raw prescription rates, but increased to 99.5% when including reasons non-prescription. For statins, rates increased from 98% to 98.6% when including reasons for non-prescription and for beta-blockers, from 82% to 93%. For aspirin, rates further increased from 99.4% to 100% and from to 99.8% to 100% for P2Y12 inhibitors.

Conclusions: We found a very high adherence to ACS guidelines for drug prescriptions at discharge when including reasons for non-prescription to drug therapy. For beta-blockers, prescription rates were suboptimal, even after taking into account reason for non-prescription. In an era of improving quality of care to achieve 100% prescription rates at discharge unless contra-indicated, pre-specification of reasons for non-prescription for cardiovascular preventive medication permits to identify remaining gaps in quality of care at discharge.

Trial registration: ClinicalTrials.gov NCT01000701.

Conflict of interest statement

Competing Interests: Dr Jüni is an unpaid steering committee or statistical executive committee member of trials funded by Abbott Vascular, Biosensors, Medtronic, and St. Jude Medical. Dr Lüscher reports receiving research grants to the institution from Abbott, Biosensors, Biotronik, Boston Scientific, and Medtronic, and consultant payments from AstraZeneca, Boehringer Ingelheim, Bayer, Merck, and Pfizer. Dr Matter reports receiving grants from MSD, Eli Lilly, AstraZeneca, and Bayer; expert testimony from MSD; payment for lectures from MSD, AstraZeneca, and Roche; and having patents from Mabimmune, CH. Dr Windecker reports receiving research contracts to the institution from Abbott, Biotronik, Boston Scientific, Biosensors, Cordis, Medtronic, St. Jude Medical and speaker fees from: Abbott, Biotronik, Boston Scientific, Biosensors, Medtronic, Eli Lilly, Astra Zeneca. All other authors have declared that no competing interests exist. The reported conflicts of interest of some co-authors do not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Figures

Figure 1. Percent of participants with recommended treatment at discharge taking into account reported reasons for non-prescription.

Abbreviations: P2Y12 inhibitors: clopidogrel, prasugrel or ticagrelor; ACEI/ATII : Angiotensin converting enzyme inhibitor/angiotensin II receptor blockers. * P2Y12 inhibitors if PCI-stent treatment (n = 1066). ** ACEI/ATII inhibitors if left ventricular ejection fraction (LVEF) ≤40% (n = 220).