BACKGROUND Use of phosphodiesterase-5 inhibitors (PDE5i) for groups 2 and 3 pulmonary hypertension (PH) is rising nationally, despite guidelines recommending against this low-value practice. Although receiving care across healthcare systems is encouraged to increase veterans' access to specialists critical for PH management, receiving care in 2 systems may increase risk of guideline-discordant prescribing. We sought to identify factors associated with prescribing of PDE5i for group 2/3 PH, particularly, to test the hypothesis that veterans prescribed PDE5i for PH in the community (through Medicare) will have increased risk of subsequently receiving potentially inappropriate treatment in Veterans Health Administration (VA). METHODS AND RESULTS We constructed a retrospective cohort of 34 775 Medicare-eligible veterans with group 2/3 PH by linking national patient-level data from VA and Medicare from 2006 to 2015. We calculated adjusted odds ratios (ORs) of receiving daily PDE5i treatment for PH in VA using multivariable models with facility-specific random effects. In this cohort, 1556 veterans received VA prescriptions for PDE5i treatment for group 2/3 PH. Supporting our primary hypothesis, the variable most strongly associated with PDE5i treatment in VA for group 2/3 PH was prior treatment through Medicare (OR, 6.5 [95% CI, 4.9-8.7]). Other variables strongly associated with increased likelihood of VA treatment included more severe disease as indicated by recent right heart failure (OR, 3.3 [95% CI, 2.8-3.9]) or respiratory failure (OR, 3.7 [95% CI, 3.1-4.4]) and prior right heart catheterization (OR, 3.8 [95% CI, 3.4-4.3]). CONCLUSIONS Our data suggest a missed opportunity to reassess treatment appropriateness when pulmonary hypertension patients seek prescriptions from VA-a relevant finding given policies promoting shared care across VA and community settings. Interventions are needed to reinforce awareness that pulmonary vasodilators are unlikely to benefit group 2/3 pulmonary hypertension patients and may cause harm.

中文翻译：

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2006年至2015年，美国在高血压中潜在使用不合适的磷酸二酯酶5抑制剂相关的因素。

背景技术尽管指南建议反对这种低价值的实践，但是在全国范围内，磷酸二酯酶5抑制剂（PDE5i）在第2组和第3组肺动脉高压（PH）中的使用正在上升。尽管鼓励在整个医疗系统中接受护理以增加退伍军人与对PH管理至关重要的专家的接触，但是在2个系统中接受护理可能会增加准则不一致的处方风险。我们试图确定与为第2/3组PH处方PDE5i相关的因素，尤其是检验以下假设：退伍军人在社区（通过Medicare）为PH规定PDE5i会增加随后接受退伍军人卫生管理局潜在不适当治疗的风险（VA）。方法和结果我们通过将2006年至2015年VA和Medicare的全国患者水平数据进行链接，建立了34 775名符合Medicare资格的退伍军人与2/3 PH组的回顾性队列。我们计算了接受每日PDE5i治疗的调整后的优势比（OR）。使用具有特定于设施的随机效应的多变量模型来评估VA中的PH。在该队列中，有1556名退伍军人接受了针对2/3 PH组的PDE5i治疗的VA处方。支持我们的主要假设，在VA中2/3组与VA中PDE5i治疗最密切相关的变量是通过Medicare进行的先前治疗（OR，6.5 [95％CI，4.9-8.7]）。与VA治疗可能性增加密切相关的其他变量包括近期右心衰竭（OR，3.3 [95％CI，2.8-3.9]）或呼吸衰竭（OR，3.7 [95％CI，3.1-4]表明的更严重的疾病。4]）和先前的右心导管检查（OR，3.8 [95％CI，3.4-4.3]）。结论我们的数据表明，当肺动脉高压患者从VA寻求处方时，错过了重新评估治疗适当性的机会-考虑到促进跨VA和社区环境共享护理的政策，这是一个相关发现。需要采取干预措施来增强人们的认识，即肺血管扩张剂不太可能使2/3组肺动脉高压患者受益，并可能造成伤害。