Wide variability in use of proven medicine: Those who would benefit most less likely to receive latest therapies

After analyzing one of the most comprehensive and representative registries of heart patients in the world, Duke University researchers found that of five therapies proven effective by clinical trials, the usage ranged from 57 percent for ACE inhibitors to 93 percent for aspirin.

The researchers studied the care received by more nearly 10,000 patients enrolled at 94 hospitals in 14 countries who are part of the Global Registry of Acute Coronary Syndromes (GRACE) to see how often the findings of new clinical trials are really being put into practice. For each of the five therapies, they looked at how many patients who were candidates for the therapy actually received it.

"There was a broad range in the usage of the therapies, which shows that while we've had some success in convincing physicians to use them, there still exists a great opportunity for improvement," said lead researcher Dr. Christopher Granger. "It is obvious that many people who could benefit from these newest therapies still aren't getting them."

Specifically, the researchers found the following usage for the five therapies for patients with severe coronary syndromes:

-- Aspirin: 93 percent received aspirin while in the hospital, and 89 percent were prescribed aspirin after discharge. Aspirin, which can keep platelets from "clumping" together and forming clots, has been a mainstay of heart care for many years.

-- Beta blockers: 81 percent received beta blockers in the hospital, 71 percent at discharge. This class of drugs protects the heart by keeping it from overreacting to stress hormones.

-- ACE inhibitors: 64 percent received this drug in the hospital, 57 percent at discharge. ACE inhibitors dilate blood vessels and act similarly to beta blockers.

-- Reperfusion therapy: Seventy percent of patients who could have received angioplasty or thrombolytic therapy (so-called clotbusting agents) actually received the therapy.

-- Low-molecular weight heparin or intravenous GP IIb/IIIa inhibitors: Only 58 percent of patients who could have benefited from this newest class of drugs actually received the therapy. These drugs work similarly to aspirin by preventing blood from clotting.

"Certain drugs, such as aspirin, have higher use, perhaps related to public awareness of their benefits," Granger said. "The other surprising and paradoxical finding is that those patients who are at the highest risk -- and therefore those who have the most to gain -- are less likely to receive proven therapies."

Also, the researchers found that in the case of aspirin, beta blockers and ACE inhibitors, patients were much more likely to receive proven therapy if their doctor was a cardiologist, Granger said.

For these reasons, Granger advocates developing a system whereby doctors and patients would have to consult a checklist before hospitalization or at discharge to ensure that the latest therapies were considered for that particular patient. Electronic systems for guiding and tracking, which have been used less in medicine than other industries for quality assurance, have been shown to improve use of effective therapies, he said.

The analysis was supported by the Duke Clinical Research Institute.