title: Frequency and practice-level variation in inappropriate aspirin use for the primary prevention of cardiovascular disease: insights from the National Cardiovascular Disease Registry's Practice Innovation and Clinical Excellence registry.
abstract: BACKGROUND
  Among patients without cardiovascular disease (CVD) and low 10-year CVD risk, the risks of gastrointestinal bleeding and hemorrhagic strokes associated with aspirin use outweigh any potential atheroprotective benefit. According to the guidelines on primary prevention of CVD, aspirin use is considered appropriate only in patients with 10-year CVD risk ≥6% and inappropriate in patients with 10-year CVD risk <6%.
  
  
  OBJECTIVE
  The goal of this study was to examine the frequency and practice-level variation in inappropriate aspirin use for primary prevention in a large U.S. nationwide registry.
  
  
  METHODS
  Within the National Cardiovascular Disease Registry's Practice Innovation and Clinical Excellence registry, we assessed 68,808 unique patients receiving aspirin for primary prevention from 119 U.S. practices. The frequency of inappropriate aspirin use was determined for primary prevention (aspirin use in those with 10-year CVD risk <6%). Using hierarchical regression models, the extent of practice-level variation using the median rate ratio (MRR) was assessed.
  
  
  RESULTS
  Inappropriate aspirin use frequency was 11.6% (7,972 of 68,808) in the overall cohort. There was significant practice-level variation in inappropriate use (range 0% to 71.8%; median 10.1%; interquartile range 6.4%) for practices; adjusted MRR was 1.63 (95% confidence interval [CI]: 1.47 to 1.77). Results remained consistent after excluding 21,052 women age ≥65 years (inappropriate aspirin use 15.2%; median practice-level inappropriate aspirin use 13.8%; interquartile range 8.2%; adjusted MRR 1.61 [95% CI: 1.46 to 1.75]) and after excluding patients with diabetes (inappropriate aspirin use 13.9%; median practice-level inappropriate aspirin use 12.4%; interquartile range 7.6%; adjusted MRR 1.55 [95% CI: 1.41 to 1.67]).
  
  
  CONCLUSIONS
  More than 1 in 10 patients in this national registry were receiving inappropriate aspirin therapy for primary prevention, with significant practice-level variations. Our findings suggest that there are important opportunities to improve evidence-based aspirin use for the primary prevention of CVD.
authors.affiliation: Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Ravi S
authors.initials: RS
authors.lastname: Hira
authors.affiliation: Mid America Heart Institute, Saint Luke's Hospital, Kansas City, Missouri.
authors.forename: Kevin
authors.initials: K
authors.lastname: Kennedy
authors.affiliation: Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Vijay
authors.initials: V
authors.lastname: Nambi
authors.affiliation: Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Hani
authors.initials: H
authors.lastname: Jneid
authors.affiliation: Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Mahboob
authors.initials: M
authors.lastname: Alam
authors.affiliation: Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Sukhdeep S
authors.initials: SS
authors.lastname: Basra
authors.affiliation: University of Colorado, Denver, Colorado.
authors.forename: P Michael
authors.initials: PM
authors.lastname: Ho
authors.affiliation: Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Anita
authors.initials: A
authors.lastname: Deswal
authors.affiliation: Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Christie M
authors.initials: CM
authors.lastname: Ballantyne
authors.affiliation: Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas; Health Policy, Quality and Informatics Program, Michael E. DeBakey Veteran Affairs Medical Center, Health Services Research and Development Center for Innovations, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Laura A
authors.initials: LA
authors.lastname: Petersen
authors.affiliation: Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas; Health Policy, Quality and Informatics Program, Michael E. DeBakey Veteran Affairs Medical Center, Health Services Research and Development Center for Innovations, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas. Electronic address: virani@bcm.edu.
authors.forename: Salim S
authors.initials: SS
authors.lastname: Virani
mesh_terms: D000368:Aged; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D016001:Confidence Intervals; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced* / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011322:Primary Prevention / Q000379:methods*; D011446:Prospective Studies; D012042:Registries; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D014481:United States / Q000453:epidemiology
chemical_list: D005343:Fibrinolytic Agents; D001241:Aspirin
keywords: aspirin; inappropriate; primary prevention