Factors Associated With Potentially Inappropriate Phosphodiesterase-5 Inhibitor Use for Pulmonary Hypertension in the United States, 2006 to 2015
Factors Associated With Potentially Inappropriate Phosphodiesterase-5 Inhibitor Use for Pulmonary Hypertension in the United States, 2006 to 2015
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DOI：
10.1161/circoutcomes.119.005993
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发表时间：
2020-05-01
影响因子：
6.9
通讯作者：
Wiener, Renda Soylemez
中科院分区：
文献类型：
--
作者：
Gillmeyer, Kari R.;Rinne, Seppo T.;Wiener, Renda Soylemez
背景：在全国范围内，使用磷酸二酯酶-5抑制剂(PDE5i)治疗2组和3组肺动脉高压(PH)的人数正在上升，尽管指南建议不要使用这种低价值的做法。虽然鼓励在医疗保健系统中接受治疗，以增加退伍军人寻求对PH管理至关重要的专家的机会，但在两个系统中接受治疗可能会增加不符合指南的处方的风险。我们试图找出与为第2/3组PH患者开PDE5i相关的因素，特别是检验这样一种假设，即退伍军人在社区(通过联邦医疗保险)为PH患者开PDE5i会增加随后在退伍军人健康管理局(VA)接受潜在不当治疗的风险。方法和结果：我们通过连接2006年至2015年来自VA和Medicare的全国患者水平数据，构建了34 775名符合联邦医疗保险资格的退伍军人和第2/3组PH患者的回顾队列。我们使用具有特定设施随机效应的多变量模型计算了每日接受PDE5i治疗VA中的PH的调整优势比(OR)。在这个队列中，1556名退伍军人接受了VA处方，用于第2/3组PH的PDE5i治疗。支持我们的初步假设，对于第2/3组PH患者，与PDE5i治疗VA最相关的变量是之前通过医疗保险治疗(OR，6.5[95%CI，4.9-8.7])。与VA治疗可能性增加密切相关的其他变量包括更严重的疾病，如最近的右心衰竭(OR，3.3[95%CI，2.8-3.9])或呼吸衰竭(OR，3.7[95%CI，3.1-4.4])和既往的右心插管(OR，3.8[95%CI，3.4-4.3])。结论：我们的数据表明，当肺动脉高压患者向VA寻求处方时，我们错过了重新评估治疗适宜性的机会--这是一个相关的发现，因为政策促进了VA和社区的共享护理。需要干预措施来加强意识，即肺血管扩张剂不太可能使2/3组的肺动脉高压患者受益，并可能造成伤害。
Background:Use of phosphodiesterase-5 inhibitors (PDE5i) for groups 2 and 3 pulmonary hypertension (PH) is rising nationally, despite guidelines recommending against this low-value practice. Although receiving care across healthcare systems is encouraged to increase veterans' access to specialists critical for PH management, receiving care in 2 systems may increase risk of guideline-discordant prescribing. We sought to identify factors associated with prescribing of PDE5i for group 2/3 PH, particularly, to test the hypothesis that veterans prescribed PDE5i for PH in the community (through Medicare) will have increased risk of subsequently receiving potentially inappropriate treatment in Veterans Health Administration (VA).Methods and Results:We constructed a retrospective cohort of 34 775 Medicare-eligible veterans with group 2/3 PH by linking national patient-level data from VA and Medicare from 2006 to 2015. We calculated adjusted odds ratios (ORs) of receiving daily PDE5i treatment for PH in VA using multivariable models with facility-specific random effects. In this cohort, 1556 veterans received VA prescriptions for PDE5i treatment for group 2/3 PH. Supporting our primary hypothesis, the variable most strongly associated with PDE5i treatment in VA for group 2/3 PH was prior treatment through Medicare (OR, 6.5 [95% CI, 4.9-8.7]). Other variables strongly associated with increased likelihood of VA treatment included more severe disease as indicated by recent right heart failure (OR, 3.3 [95% CI, 2.8-3.9]) or respiratory failure (OR, 3.7 [95% CI, 3.1-4.4]) and prior right heart catheterization (OR, 3.8 [95% CI, 3.4-4.3]).Conclusions:Our data suggest a missed opportunity to reassess treatment appropriateness when pulmonary hypertension patients seek prescriptions from VA-a relevant finding given policies promoting shared care across VA and community settings. Interventions are needed to reinforce awareness that pulmonary vasodilators are unlikely to benefit group 2/3 pulmonary hypertension patients and may cause harm.