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Use of Oral Antithrombotic Agents Among Health Maintenance Organization Members With Atherosclerotic Cardiovascular Disease
Jonathan B. Brown, MPP, PhD;
Thomas E. Delea, MSIA;
Gregory A. Nichols, PhD;
John Edelsberg, MD, MPH;
Patricia J. Elmer, PhD, MS;
Gerry Oster, PhD
Arch Intern Med. 2002;162:193-199.
Background Numerous randomized trials document the value of antithrombotic agents
for the treatment of cardiovascular disease (CVD). Although antithrombotic
agents are often prescribed at hospital discharge after CVD-related events,
much less is known about the ongoing use of such agents.
Methods We examined the use of oral antithrombotic agents among a random sample
of 2500 persons with atherosclerotic CVD who were enrolled in Kaiser Permanente
Northwest Region, a not-for-profit group-model health maintenance organization.
Study subjects were identified based on a diagnosis of coronary heart disease,
ischemic stroke or transient ischemic attack, or peripheral arterial disease
in outpatient problem lists, visit records, and hospital discharge abstracts.
Use of prescription antithrombotic agents was identified from pharmacy dispensing
records. Regular use of aspirin, recall of aspirin advice and education, and
other patient characteristics were ascertained by mail survey.
Results Among the 1844 subjects who returned the survey and answered the question
regarding aspirin use, 84% were using either aspirin (72%) or a prescription
antithrombotic agent (12%), typically warfarin sodium. Antithrombotic therapy
was relatively underused in persons with peripheral arterial disease (75%
used an antithrombotic agent and 62% used aspirin). Use of antithrombotic
agents, including aspirin, did not differ by age but was higher among men
(87%, 76%) than women (81%, 67%). Nearly all subjects reported having received
aspirin education (94%) or advice (81%); recall of education or advice was
associated with a dramatically higher likelihood of using antithrombotic agents.
To a lesser extent, so was contact with a cardiologist or vascular surgeon
during the prior year.
Conclusions High rates of use of antithrombotic agents can be achieved among persons
with CVD in integrated not-for-profit health systems with mechanisms in place
to encourage such use, including guidelines, messages to clinicians, nurse
care management, alerts and routines embedded in electronic medical records,
and direct mailings to patients. Continued efforts should be made in all settings
to optimize the use of antithrombotic therapy among persons at an elevated
risk of atherothrombotic events.
From the Center for Health Research, Portland, Ore (Drs Brown, Nichols,
and Elmer); and Policy Analysis Inc, Brookline, Mass (Mr Delea and Drs Edelsberg
and Oster). Policy Analysis Inc was a paid consultant to Sanofi-Synthelabo,
New York, NY, and Bristol-Myers Squibb Co, Princeton, NJ, on the development
of a health-economics program for the prescription antiplatelet agent, clopidogrel
bisulfate (Plavix), while this study was conducted.
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