PROVIDER-LEVEL VARIATION IN NOVEL CARDIOVASCULAR MEDICATION PRESCRIPTION AMONG PATIENTS HOSPITALIZED FOR HEART FAILURE AND CORONARY ARTERY DISEASE IN THE VETERANS AFFAIRS SYSTEM

Abstract

Therapeutic Area: Preventive Cardiology Best Practices – clinic operations, team approaches, outcomes research Background: Novel therapies such as angiotensin receptor-neprilysin inhibitors (ARNI), sodium-glucose cotransporter-2 inhibitors (SGLT2i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA) have well-established benefit for patients with heart failure (HF) and coronary artery disease (CAD), but use remains low. We aimed to characterize provider-level variation in the use of these medications in the Veterans Health Administration (VA). Methods: Using VA health record and administrative data, two patient cohorts were retrospectively identified with hospitalization from 2017-2023 for either HF or CAD with concurrent Type 2 diabetes (T2D). Provider-level data for use of ARNI and SGLT2i for HF and SGTL2i or GLP-1 RA for CAD+T2D were assessed, including at hospital admission, discharge, or within 6 months of discharge. Providers were considered users if they had an outpatient visit with a patient who had a filled prescription for a given medication within 6 months of discharge, regardless of when or by whom the prescription was written. Providers with above-median utilization for all 3 classes were considered high utilizers. Histograms and adjusted median odds ratios were used to characterize provider-level variability in prevalent use of novel medications by medical subspecialty. Results: The HF and CAD+T2D cohorts included 83,849 and 71,678 unique patients, respectively, with 14,645 providers. Distributions of providers by prevalent use of each respective medication class are shown by medical subspecialty in the Figure. Mean prevalent use over the study period ranged from 17-44% for a given specialty and medication class. Most providers had <50% use of each medication class, though there were smaller numbers of providers with near-100% prevalent use of novel medications. Endocrinology and cardiology had the highest proportions of high utilizers (44% and 39%, respectively, compared with 24% and 15% for primary care and nephrology). Adjusted median odds ratios across all providers over the full study period were 1.7 and 1.8 for ARNI and SGLT2i in the HF cohort and 1.8 in the CAD+T2D cohort. Conclusions: Cardiologists and endocrinologists were mostly likely to use novel cardiovascular medications, but there was substantial provider-level variation across all prescribing subspecialities. Further research is needed to identify implementation strategies to improve uptake among all providers.