Michelle L. O'Donoghue, MD, MPH


January 04, 2016

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Hi. I'm Dr Michelle O'Donoghue, reporting for theheart.org on Medscape. I am at the AHA [American Heart Association 2015 Scientific Sessions] in Orlando, and one of the great things about attending these sessions is the opportunity to discuss different clinical practices with people around the world. It struck me about how many different regional variations there are in clinical practice and therapeutic decision-making.

One very hot topic is duration of dual-antiplatelet therapy (DAPT). It struck me as quite interesting that in Europe, there has been more of a move toward shorter durations of DAPT, whereas in the United States, there's been a push towards prolonging DAPT—in particular, in response to the results of the DAPT Study.[1]

As I was thinking about those regional variations, it made me take a step back and really think about what factors influence my decision to prescribe a particular therapy or to practice medicine [in a particular way]? Of course, there are some factors, such as whether or not a new therapeutic is available in a formulary, or whether or not insurers are going to reimburse a therapy.

But also, when I really thought about it, how much of our decision-making is actually guided by the decisions made by our peers? By way of example, I have the opportunity to attend at both Mass General as well as Brigham and Women's Hospital in Boston. That provides me with a unique opportunity to see differences in practice patterns between the two different institutions.

Some of our decisions are clearly guided by guidelines, and it's important to use objective evidence to help our decision-making. But occasionally, I've noticed that between the two different hospitals, there are some unexplained differences that seemed to be institution-dependent, such as our willingness to use an IVC [inferior vena cava] filter, differences in timing of clopidogrel preloading, or which P2Y12 inhibitor we might reach for.

What is it that influences us? When we see our peers prescribing a therapy a certain way, do we follow lockstep? Or are there other factors that come into play that we're not as cognizant of?

This question is particularly relevant when it comes to some of the novel therapies. I remember after the results of PLATO [Platelet Inhibition and Patient Outcomes],[2] when we saw that ticagrelor had a mortality benefit over clopidogrel: Initially, a lot of physicians said, "Wow, people are going to readily adopt this therapy," and now, several years later, people have embraced ticagrelor.

But initially, there's quite a great deal of inertia when it comes to prescribing a new therapy. The same is perhaps true of the angiotensin-receptor/neprilysin inhibitor [Entresto™ (sacubutril/valsartan)], which has been shown to have a mortality benefit over a standard ACE inhibitor.[3]

Yet, even though that medication has now become available at the formulary at my hospital, I was asking myself the other day, "Why haven't I prescribed it yet?" Am I waiting for the next clinician to start prescribing that drug as well, before I start making my own adoption of change in clinical practice?

It's always good to think about the factors that influence our decision-making. Certainly, pharmaceutical companies are interested to know better what different factors may be at play when it comes to a decision to prescribe a therapy for the first time. How much are we influenced by key opinion leaders, but also the other clinicians in our practice?

After AHA, I'm going to take more of an active role in thinking about what different factors are influencing my choices, and perhaps being the first to prescribe a therapy if I feel like the evidence is there to support the decision-making.

I'd be interested to hear from you on this subject. Do you think that the practice of your peers influences your decision-making as well? How do we move away from that and make sure that all of our decisions are really based on the evidence alone? I'd love to hear from you.

Coming to you from AHA, this is Dr Michelle O'Donoghue for theheart.org on Medscape.


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