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Use of angiotensin receptor blockers in the VA, 2000-2009 – why so much variation?

Gellad WF, Lowe J, Good CB, Donohue J. Use of angiotensin receptor blockers in the VA, 2000-2009 – why so much variation? Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA.


Research Objective: ACE inhibitors (ACE-I) and Angiotensin Receptor Blockers (ARB) are important medication classes with similar indications for use. Although there are no significant differences in efficacy between the two classes, ARBs are substantially more expensive. Regional variation in healthcare use has become a primary indicator of inefficiency in the healthcare system, yet little is known about variation in medication use. We used national data on prescribing of ACE-Is and ARBs in the VA, where drug price and drug coverage are consistent, and focused on prescribing patterns to assess 1) variation in use of ARBs among VA Medical Centers (VAMC) in 2009, and 2) the change in use of ARBs over time from 2000 to 2009. Study Design: We aggregated national VA data on outpatient ACE-I and ARB use for fiscal years 2000-2009 at the VAMC-level. We calculated the proportion of patients who use ARBs among those who require renin-angiotensin inhibitors, by dividing the number of patients on ARBs by the number of patients on either ACE-I or ARB at each VAMC. We then assessed the 10-year growth rate in the proportion of patients on ARBs ((2009 proportion - 2000 proportion)/2000 proportion). To calculate the potential savings for VAMCs if they were to use fewer ARBs, we determined how many fewer ARB prescriptions a high-use VAMC would fill if it used ARBs at the same rate as an average facility. Population Studied: We studied 132 VAMCs. There were 1.7 million patients on these medications with 15.7 million prescriptions in 2009 alone. Principal Findings: For VAMC patients taking either an ACE-I or ARB in 2000, the median proportion using ARBs was 6.8%, with a range from 0.2% to 15.7%. The median rate of growth in this proportion over 10 years was 194% (IQR 104% to 285%) but also showed sizeable variation. Four VAMCs had less than 5% growth over the 10 years, while seven VAMCs had over 1000% growth, with 6 of those 7 VAMCs located in the same two states. In 2009, the median proportion of patients taking an ACE-I or ARB who used ARBs was 17.2% (IQR 13.4% to 21.1%), with a range from 6.4% to 33.6%. Almost 80% of VAMCs in the bottom half of use are located in the South. If the highest-use VAMC in 2009 (with a proportion of 33.6%) had the same proportion of ARB use as the median facility, it alone would save $205,292 yearly. If that VAMC filled ARBs at the same rate as the least-using facility, it would save $344,625, or 1.3% of its total yearly drug costs. Conclusions: There is substantial variation across VAMCs in the proportion of patients using ARBs, with a steady increase over the past decade. Although some increase over time in the use of ARBs over ACE-I is to be expected due to side effects, it is unlikely that medical indications alone explain this variation and this increase over time. Implications for Policy, Delivery or Practice: Cost-effective, high-value, and efficient prescribing should be a target of quality improvement programs, even in systems with robust formulary management, such as the VA.

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