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Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1057 — National Patterns of Guideline-Discordant Prescribing of Phosphodiesterase-5-Inhibitors for Pulmonary Hypertension in VHA

Lead/Presenter: Renda Wiener, COIN - Bedford/Boston
All Authors: Wiener RS (Bedford/Boston Center for Healthcare Organization & Implementation Research) Lee KM (Bedford/Boston Center for Healthcare Organization & Implementation Research) Kim D (Bedford/Boston Center for Healthcare Organization & Implementation Research) Rinne ST (Bedford/Boston Center for Healthcare Organization & Implementation Research) Klings ES (Boston University School of Medicine) Rose AJ (Boston University School of Medicine) Miller DR (Bedford/Boston Center for Healthcare Organization & Implementation Research)

Inappropriate care, such as prescribing ineffective medicines, costs VHA billions and exposes Veterans to harm. Pulmonary hypertension (PH) is increasingly detected with rising use of echocardiography and presents treatment challenges. While phosphodiesterase-5-inhibitors (PDE5i) are effective for Group I PH, clinical guidelines and the Choosing Wisely Campaign recommend against PDE5i therapy for Groups II and III PH (the most common types of PH) due to a lack of benefit, potential for harm, and high cost. We sought to determine national patterns of PDE5i prescribing for PH in VHA.

We conducted a retrospective cohort analysis including all Veterans prescribed PDE5i for PH between FY2005-2012, supplemented by gold-standard chart abstraction on a random sample (n = 241). Patients were identified by the presence of an ICD-9CM diagnosis code for PH and >=1 outpatient prescription for daily PDE5i therapy from any VA site. Our primary outcome was the proportion of Veterans who received inappropriate PDE5i, as determined by guideline recommendations (Group I PH: appropriate; Groups II/III PH: inappropriate; Group IV/V PH: uncertain value), among all Veterans prescribed PDE5i for PH. Secondary outcomes included proportion of treated patients who received guideline-recommended confirmatory right heart catheterization.

We identified 108,777 Veterans with PH, 2,790 (2.6%) of whom received daily PDE5i therapy. Among treated Veterans, 541 (19%) received appropriate treatment, 1,711 (61%) inappropriate treatment, and 358 (13%) treatment of uncertain value. The number of inappropriately treated patients increased more than 10-fold over the study period, from 53 in 2005 to 748 in 2012. Based on chart abstraction, only half (46%, 111/241) of PDE5i-treated Veterans underwent guideline-recommended right heart catheterization to confirm presence or type of PH.

Most Veterans with PH do not receive PDE5i therapy. However, among treated Veterans, almost two-thirds of PDE5i prescriptions are inconsistent with guideline recommendations, exposing Veterans to potential harm and creating a large cost burden for VHA.

At costs of $10,000-$13,000 per patient-year and no clear benefit, de-implementation of PDE5i treatment for Groups II and III PH is a potential high-yield target to improve value, safety, and quality of care for Veterans with an increasingly common clinical condition.