Hospital Variability in Use of Anticoagulant Strategies During Acute XXXX Treated With an Early Invasive Strategy.

@entity1 @entity583 @entity548
BACKGROUND: During a @entity583 , no single best approach of systemic anticoagulation is recommended, likely due to a lack of comparative effectiveness studies and trade-offs between treatments. METHODS AND RESULTS: We investigated the patterns of use and site-level variability in anticoagulant strategies (unfractionated heparin [UFH] only, low-molecular-weight heparin [LMWH] only, UFH+LMWH, any bivalirudin) of 63 796 @entity1 with a principal diagnosis of @entity583 treated with an early invasive strategy with percutaneous coronary intervention at 257 hospitals. About half (47%) of @entity1 received UFH only, 6% UFH+LMWH, 7% LMWH only, and 40% bivalirudin. Compared with UFH, the median odds ratio was 2.90 for LMWH+UFH, 4.70 for LMWH only, and 3.09 for bivalirudin, indicating that 2 "identical" @entity1 would have a 3- to 4-fold greater likelihood of being treated with anticoagulants other than UFH at one hospital compared with another. We then categorized hospitals as low- or high-users of LMWH and bivalirudin. Using hierarchical, multivariate regression models, we found that low bivalirudin-using hospitals had higher unadjusted @entity548 rates, but the risk-adjusted and anticoagulant-adjusted @entity548 rates did not differ across the hospital anticoagulation phenotypes. Risk-standardized mortality and risk-standardized length of stay also did not differ across hospital phenotypes. CONCLUSIONS: We found substantial site-level variability in the choice of anticoagulants for invasively managed acute @entity583 @entity1 , even after accounting for @entity1 factors. No single hospital-use pattern was found to be clinically superior. More studies are needed to determine which @entity1 would derive the greatest benefit from various anticoagulants and to support consistent treatment of @entity1 with the optimal anticoagulant strategy.
