Quality improvement initiative cuts use of triple therapy after PCI
A hospital-wide quality improvement initiative including adoption of institutional guidelines, new prescribing prompts and a teaching curriculum was associated with a reduction in the use and duration of triple therapy after PCI, data show.
The American College of Cardiology expert consensus pathway recommends against the routine use of triple therapy after PCI, Eric A. Secemsky, MD, MSc, RPVI, FACC, FSCAI, FSVM, director of vascular intervention at Beth Israel Deaconess Medical Center, director of vascular research at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology and assistant professor of medicine at Harvard Medical School, and colleagues wrote in Catheterization and Cardiovascular Interventions. In patients on oral anticoagulation with a high risk for ischemic events, guidelines recommend prescribing triple therapy — an anticoagulant, a P2Y12 inhibitor and aspirin — for no more than 30 days.
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“Research has shown that national consensus statements, despite being evidence-based, are not always readily translated into clinical practice,” Secemsky and colleagues wrote. “A continuous quality improvement program may be helpful to facilitate the adoption of these guidelines into clinical practice. Proposed interventions that enhance provider adherence to guidelines include chart‐based reminders, computerized decision support programs, the education of physicians through local opinion leaders, and surveys of perceptions and prescribing patterns.”
Secemsky and colleagues analyzed data from a hospital‐wide quality improvement initiative developed to minimize time on triple therapy after PCI. Interventions included institutional guidelines emphasizing discharge on double therapy (oral anticoagulation plus a P2Y12 inhibitor) or reducing triple therapy duration to 30 days or less; changes to the computerized decision‐support system; and an educational curriculum for house staff on cardiology service.
The researchers reviewed data from 431 patients who underwent PCI and received oral anticoagulation at discharge 18 months before and after the initiative was implemented (2017-2020) along with a faculty survey assessing prescribing practices to evaluate the efficacy of the interventions. The mean age of patients was 74 years; 80.1% were white and 24.9% were women. The most common indications for oral anticoagulation were atrial fibrillation (70.1%) and left ventricular dysfunction (11.4%).
The mean duration of triple therapy decreased from 58.7 days to 37.8 days (P = .02) and the proportion of patients discharged on triple therapy for fewer than 30 days increased from 24% to 37% (P = .019) after the intervention was implemented.
“In addition, there was greater documentation in the discharge summary/instructions of the triple therapy duration plan post‐PCI following the guidelines intervention, increasing from 80% to 89%,” the researchers wrote.
Of the surveyed faculty (n = 20), 75% reported familiarity with the guidelines and 57.9% reported using them to make therapy decisions.
“At other academic tertiary institutions where prescribing practices post‐PCI for patients on oral anticoagulants remain heterogeneous, similar approaches should be considered to incorporate consensus recommendations into clinical practice,” the researchers wrote.
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