Multivariable Analysis of Primary Care Physician Adherence to Guideline-recommended Pharmacotherapy of Stable Coronary Artery Disease

Aim. To study predictors of primary care physician adherence to guideline-recommended pharmacotherapy of stable coronary artery disease.

Material and methods. This pharmacoepidemiologic cross-sectional study was conducted in primary care setting of Moscow. 805 patients (mean age 68.9±9.9 years, males 51.4%) with established stable coronary artery disease (SCAD) were included. Demography, medical history, prescribed pharmacological treatment data were obtained. Physician adherence to guideline-recommended pharmacotherapy (GRP) of SCAD was evaluated based on the Class I guideline recommendations. Pharmacotherapeutic guideline adherence index (PGAI) was introduced as composite quality indicator, calculated in line with “all-or-none” rule and in regard with documented contraindications. To search for predictors of adherence the patient population was divided in two groups by level of physician adherence measured by PGAI. Statistical analysis was performed by IBM SPSS Statistics 16.0, the level of statistical significance was set at p<0.05.

Results. The prescription rates of essential drug therapies of SCAD (regarding contraindications) were quite adequate: beta-blockers/calcium channel blockers – 90,1%, acetylsalicylic acid/clopidogrel/oral anticoagulants – 95,7%, statins/ezetimibe – 86,3%, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers – 87,6%. 82,9% (n=667) of patients were prescribed treatment for SCAD in compliance with the guidelines. Suboptimal pharmacotherapy was identified in 17,1% (n=138) of patients. These groups were similar in sex distribution (males 50,4 vs. 56,5%; p=0,188). Mean age tended to be lower in GRP adherent group (68,5±9,9 vs. 70,6±10,0 years; p=0,052). Bivariable analysis showed that good adherence to guideline-recommended pharmacotherapy was associated with higher prevalence of stable angina (66,4 vs. 53,6%; p=0,004), arterial hypertension (93,3 vs. 79,7%; p<0,001) and dyslipidemia (21,4 vs. 9,4%; p<0,001) and with lower prevalence of myocardial infarction (48,1 vs. 67,4%; p<0,001). Logistic multivariable regression model (gender, age, 6 medical history variables) identified 6 patient-related factors that were significantly associated with physician adherence to guideline-recommended pharmacotherapy: age (odds ratio [OR] 0,97; 95% confidence interval [CI] 0,95-0,99; p=0,009), arterial hypertension (OR 3,89; 95%CI 2,19-6,90; p<0,001), dyslipidemia (OR 2,31; 95%CI 1,23-4,34; p=0,009), chronic heart failure (OR 1,95; 95%CI 1,06-3,61; p=0,032), revascularization (OR 2,14; 95%CI 1,33-3,45; p=0,002), myocardial infarction (OR 0,28; 95%CI 0,16-0,48; p<0,001).

Conclusion. Primary care cardiologist adherence to guideline-recommended pharmacotherapy of SCAD was satisfactory evaluated as 82,9% by composite indicator PGAI. Arterial hypertension, heart failure, dyslipidemia и revascularization were predictors of better physician adherence. History of myocardial infarction and older age were risk factors of non-adherence. Identification of patient-related factors associated with underperformance may facilitate tailoring quality improvement interventions in primary care of coronary patients.

1. EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries; principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J. 2001;22(7):554-72. DOI:10.1053/euhj.2001.2610.

2. Eastaugh J.L., Calvert M.J., Freemantle N. Highlighting the need for better patient care in stable angina: results of the international Angina Treatment Patterns (ATP) Survey in 7074 patients. Fam Pract. 2005;22(1):43-50. DOI:10.1093/fampra/cmh711.

3. Kotseva K., De Backer G., De Bacquer D., et al. Lifestyle and impact on cardiovascular risk factor control in coronary patients across 27 countries: Results from the European Society of Cardiology ESC-EORP EUROASPIRE V registry. Eur J Prev Cardiol. 2019;26(8):824-35. DOI:10.1177/2047487318825350.

4. Kumbhani D.J., Fonarow G.C., Cannon C.P., et al. Get With the Guidelines Steering Committee and Investigators. Temporal trends for secondary prevention measures among patients hospitalized with coronary artery disease. Am J Med. 2015;128(4):426.e1-9. DOI:10.1016/j.amjmed.2014.11.013.

5. Tolpygina S.N., Martsevich S.Y. Study of a trend in the frequency of using main drug classes indicated for the treatment of patients with chronic coronary heart disease in 2004 to 2014: data from the CHD PROGNOSIS registry. The Clinician. 2016;10(1):29-35 (In Russ.) DOI:10.17650/1818-8338-2016-10-1-29-35.

6. Everett W., ed. Improving Physician Adherence to Clinical Practice Guidelines: Barriers and Strategies for Change. London, UK: New England Healthcare Institute; 2008.

7. Kumbhani D.J., Fonarow G.C., Cannon C.P., et al. Get With the Guidelines Steering Committee and Investigators. Predictors of adherence to performance measures in patients with acute myocardial infarction. Am J Med. 2013;126(1):74.e1-9. DOI:10.1016/j.amjmed.2012.02.025.

8. Hoorn C.J.G.M., Crijns H.J.G.M., Dierick-van Daele A.T.M., Dekker L.R.C. Review on Factors Influencing Physician Guideline Adherence in Cardiology. Cardiol Rev. 2019;27(2):80-6. DOI:10.1097/CRD.0000000000000207.

9. Task Force Members, Montalescot G., Sechtem U., Achenbach S., et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003. DOI:10.1093/eurheartj/eht296.

10. Stable ischemic heart disease. Clinical guidelines. Ministry of Health of Russia, 2016 [cited by Apr 05, 2020]. Available at: http://kokb45.ru/wp-content/uploads/2018/06/Stabilnaya-ishemicheskaya-bolezn-serdtsa.pdf (In Russ.)

11. Nolan T., Berwick D.M. All-or-none measurement raises the bar on performance. JAMA. 2006;295(10):1168-70. DOI:10.1001/jama.295.10.1168.

12. The pursuit of responsible use of medicines: sharing and learning from country experiences. Geneva: World Health Organization; 2012.

13. Eapen Z.J., Fonarow G.C., Dai D., et al. Get With The Guidelines Steering Committee and Hospitals. Comparison of composite measure methodologies for rewarding quality of care: an analysis from the American Heart Association's Get With The Guidelines program. Circ Cardiovasc Qual Outcomes. 2011;4(6):610-8. DOI:10.1161/CIRCOUTCOMES.111.961391.

14. El Hadidi S., Darweesh E., Byrne S., Bermingham M. A tool for assessment of heart failure prescribing quality: A systematic review and meta-analysis. Pharmacoepidemiol Drug Saf. 2018;27(7):685-94. DOI:10.1002/pds.4430.

15. Suvorov A.Y., Martsevich S.Y., Kutishenko N.P. et al. The way of assessing the adherence to modern drug therapy clinical guidelines aimed at reducing the risk of recurrent stroke (according to the LIS2 register). Rational Pharmacotherapy in Cardiology. 2015;11(1):45-52 (In Russ.) DOI:10.20996/1819-6446-2015-11-1-45-52.

16. McGinty J., Anderson G. Predictors of physician compliance with American Heart Association guidelines for acute myocardial infarction. Crit Care Nurs Q. 2008;31(2):161-72. DOI:10.1097/01.CNQ.0000314476.64377.12.

17. Redfors B., Angerås O., Råmunddal T., et al. Trends in Gender Differences in Cardiac Care and Outcome After Acute Myocardial Infarction in Western Sweden: A Report From the Swedish Web System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). J Am Heart Assoc. 2015;4(7):e001995. DOI:10.1161/JAHA.115.001995.

18. Lewis W.R., Ellrodt A.G., Peterson E. et al. Trends in the use of evidence-based treatments for coronary artery disease among women and the elderly: findings from the get with the guidelines quality-improvement program. Circ Cardiovasc Qual Outcomes. 2009;2(6):633-41. DOI:10.1161/CIRCOUTCOMES.108.824763.

19. Austin P.C., Tu J.V., Ko D.T., Alter D.A. Factors associated with the use of evidence-based therapies after discharge among elderly patients with myocardial infarction. CMAJ. 2008;179(9):901-8. DOI:10.1503/cmaj.080295.

20. Pepió Vilaubí J.M., Orozco-Beltrán D., Gonçalves A.Q., et al. Adherence to European Clinical Practice Guidelines for Secondary Prevention of Cardiovascular Disease: A Cohort Study. Int J Environ Res Public Health. 2018;15(6):1233. DOI:10.3390/ijerph15061233.