Elsevier

American Heart Journal

Volume 168, Issue 3, September 2014, Pages 340-345
American Heart Journal

Clinical Investigation
Interventional Cardiology
Clopidogrel prescription filling delays and cardiovascular outcomes in a pharmacy system integrating inpatient and outpatient care: Insights from the Veterans Affairs CART Program

https://doi.org/10.1016/j.ahj.2014.05.012Get rights and content

Background

Delays in filling clopidogrel prescriptions after percutaneous coronary intervention (PCI) have been demonstrated previously and associated with adverse outcomes.

Methods

This was a retrospective cohort study of 11,418 patients undergoing PCI with stent placement in Veterans Affairs (VA) hospitals between January 1, 2005, and September 30, 2010. Data were obtained from the national VA Clinical Assessment, Reporting, and Tracking Program, including post-PCI clopidogrel prescription fill date and outcomes of myocardial infarction and death within 90 days of discharge. Patients who did not fill a clopidogrel prescription on the day of discharge were considered to have a delay. Multivariable models assessed the association between clopidogrel delay and myocardial infarction/death using clopidogrel delay as a time-varying covariate.

Results

Of the patients, 7.2% had a delay in filling their clopidogrel prescription. Delay in filling clopidogrel was associated with increased risk of major adverse events (hazard ratio 2.34, 95% CI 1.66-3.29, P < .001). The percentage of patients who delayed filling varied by hospital, ranging from 0 to 43.5% with a median of 6.2% (P < .001, χ2 for difference across hospitals) and a median odds ratio of 2.13 (95% CI 1.85-2.68) suggesting large site variation in clopidogrel delay across hospitals.

Conclusions

In a health care system with integrated inpatient and outpatient pharmacy services, 1 in 14 patients delays filling a clopidogrel prescription. The large site variation suggests a need to identify best practices that allow hospitals to optimize prescription filling at discharge to potentially improve patient outcomes.

Section snippets

Setting

The VA Clinical Assessment, Reporting, and Tracking (CART) Program is a national clinical quality program that tracks coronary procedures in all VA catheterization laboratories. In contrast to some catheterization laboratory registries, the CART Program mandates reporting of all catheterization laboratory cases, decreasing the likelihood of selection bias in the reported cases. The CART uses a point-of-care software application embedded in the VA electronic health record that allows providers

Results

The analytic cohort consisted of 8,382 patients, 7,775 of whom filled their clopidogrel prescription on the day of discharge and 607 (7.2%) of whom delayed between 1 and 30 days. In patients with a delay in filling clopidogrel prescription, the mean delay time was 14.4 days (SD 11.3 days), and the median delay was 11 days (interquartile range 3-28 days). In univariate analysis, patients who delayed filling their prescription more often presented for PCI in cardiogenic shock (P < .001) and had a

Discussion

In a large, national health care delivery system with an integrated inpatient and outpatient pharmacy service, we found that approximately 1 in 14 patients delayed filling clopidogrel prescriptions after PCI with stent implantation. Moreover, delay in filling a clopidogrel prescription was associated with increased risk of near-term major adverse events after PCI. At the patient level, delay in clopidogrel prescription filling was associated with increased risk of adverse outcomes. If patients

Disclosure

Dr Byrd, investigator: Medtronic clinical trial. Dr Bhatt, advisory board: Medscape Cardiology; board of directors: Boston VA Research Institute and Society of Chest Pain Centers; chair: AHA Get With The Guidelines Science Subcommittee; honoraria: ACC (Editor, Clinical Trials, Cardiosource), Duke Clinical Research Institute (clinical trial steering committees), Slack Publications (Chief Medical Editor, Cardiology Today Intervention), and WebMD (CME steering committees); other: Senior Associate

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