Ticagrelor Use Varies Greatly Between Hospitals, Even Without Added Cost Considerations

Dennis T. Ko, MD, MSc

New research from investigators in Canada describes a lack of optimized uptake of ticagrelor in older patients with acute coronary syndromes (ACS).

A 23,000-patient analysis encompassing 4 years of data, results of the study detail increases in overall ticagrelor use but also provide insight into significant hospital-level variation in use, with hospital‐specific prescribing rates ranging from 0% to 83.6% among the hospitals included and those with advanced aged and comorbidities less likely to receive the oral P2Y12 inhibitor.

“Even though randomized trial data emerged in 2009 that showed ticagrelor was associated with an incremental benefit compared with clopidogrel, we found only half of all patients with ACS over 65 years were prescribed ticagrelor at hospital discharge,” wrote investigators. “We observed that older patients or patients who had more medical comorbidities were less likely to be treated with ticagrelor. Yet, nonclinical factors such as physician and hospital factors appeared to be even more influential in the decision for ticagrelor prescription.”

Citing data suggesting ticagrelor’s adoption had been hampered by increased cost in the US, a team of investigators led by Dennis T. Ko, MD, MSc, of the University of Ontario, sought to estimate trends in ticagrelor use without added cost consideration. To do so, investigators designed an observational population-based cohort study of patients aged 65 years and older hospitalized with their first ACS in Ontario, Canada from April 2014-March 2018 identified using linked data from the Ontario Drug Benefit database, Canadian Institute for Health Information and Discharge Abstract Database, Ontario Registered Persons Database, and the Statistics Canada database.

During the aforementioned time period, investigators identified 92,657 patients with a first ACS. After application of inclusion criteria, which required patients to have be prescribed ticagrelor or clopidogrel during the first 7 days following index discharge and have at least 1 year of follow-up data, a final analytical cohort of 23,962 patients from 156 hospitals was identified for inclusion. This cohort had a mean age of 76.3 years and 59.7% were men.Of the 23,962 patients identified for inclusion, 10,185 patients received ticagrelor and 13,777 received clopidogrel.

For the purpose of analysis, sequence of multivariable logistic regression models were used to assess the incremental impact of patient, physician, and hospital characteristics on ticagrelor use and between-hospital variability was quantified using median odds ratios (OR). Investigators noted hierarchical regression models were used to identify significant predictors of ticagrelor use.

From 2014-2015 to 2017-2018, the overall prevalence of ticagrelor use increased from 32.6% to 51.8%. However, investigators highlighted a significant degree of variation in ticagrelor use between hospitals, with rates of use ranging from 0% to 83.6% of patients. When assessing patient characteristics, lower odds of ticagrelor use were observed for those with advanced age and those with comorbidities. Further analysis suggested being admitted to a rurally local hospital was associated with a halving in the odds of being prescribed ticagrelor (OR, 0.49 [95% CI 0.32-0.77]; P <.002)while being managed by a cardiologist during the index hospitalization was associated with a nearly 3-fold increase in odds of having a ticagrelor prescription (OR, 2.80 [95% CI, 2.36-3.33]; P <.001).

“Even though we adjusted for all the known and measurable patient, physician, and hospital factors, we observed substantial hospital variation that the use of ticagrelor varied >2.5 times even after adjustment,” investigators wrote. “This observation suggests that many unmeasured factors still exist that could account for difference in ticagrelor adoption across the hospitals. Those factors may include the hospital formulary system—the prescription restriction policies at each hospital may influence prescribing patterns.”

This study, “Hospital‐Level Variation in Ticagrelor Use in Patients With Acute Coronary Syndrome,” was published in the Journal of the American Heart Association.