Semester

Summer

Date of Graduation

2003

Document Type

Dissertation

Degree Type

PhD

College

School of Pharmacy

Department

Pharmaceutical Sciences

Committee Chair

Suresh S. Madhavan

Committee Co-Chair

Mayur M. Amonkar

Abstract

Acute myocardial infarction (AMI) is associated with high mortality and costs to the US healthcare system. Beta-blockers are known to reduce mortality and re-infarction rates when used for long-term prevention following an AMI. They are recommended by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines in post-AMI patients. However, this therapy is both underused (error of omission in eligible patients) and misused (error of commission in ineligible patients). This study involved two phases. Phase one included evaluating utilization of beta-blockers in a Medicaid population and determining the effect of their utilization on patient outcomes such as mortality, morbidity, utilization of healthcare services and expenditures. Phase two involved determining the association of physician-related factors such as knowledge of contraindications, willingness to prescribe, physician demographics and physician practice characteristics on their beta-blocker prescribing behavior. Phase one of the study revealed 37% inappropriate (misuse and underuse) utilization. During the 12-month follow-up after the incident AMI the appropriately prescribed group had a significantly lower all-cause mortality and lower, but insignificant, cardiac mortality compared to the inappropriately prescribed group. The appropriately prescribed group had significantly higher cardiovascular morbidity and higher utilization in the follow-up period. However, there were indications that the appropriate group was more severely ill as compared to the inappropriate group. Thus, the increase in morbidity and utilization could be due to patient severity rather than appropriate therapy. In phase two, a survey was mailed to 1,019 physicians involved in post-AMI care in WV, of which 261 (25.61%) responded. Physician knowledge of contraindications was not associated with their self-reported beta-blocker prescribing behavior. Physicians' willingness to prescribe was positively associated with their beta-blocker prescribing behavior. Younger age and affiliation with a larger hospital were associated with better beta-blocker prescribing behavior. Multivariate analysis including knowledge, willingness to prescribe, demographics and practice characteristics revealed that willingness to prescribe was the only significant predictor of their beta-blocker prescribing behavior. Findings of this phase indicated a profile of general specialty/family practice physician, older in age, non-university or non-hospital affiliated, and attached to a smaller hospital as the target for interventions to improve beta-blocker prescribing behavior.

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