Coronary angiography under-prescribed for both Medicare managed care and fee-for-service heart attack patients
BOSTON—November 16, 2000—Medicare patients enrolled in managed-care plans were significantly less likely than those with traditional Medicare fee-for-service coverage to receive needed coronary angiography—a potentially lifesaving diagnostic procedure—following a heart attack, even though the procedure is a highly recommended practice, according to a study in today’s issue of the New England Journal of Medicine.
"Nearly a fifth of the Medicare population is in a managed-care plan," says the study’s lead author, Edward Guadagnoli, associate professor at Harvard Medical School’s Department of Health Care Policy. "While these numbers increase, we’ve seen a decline in the growth of overall medical expenditures, causing concern about the quality of care provided to managed-care enrollees, and particularly the elderly, the most vulnerable patients."
The study found that the elderly heart attack patients who needed coronary angiography, or Class I patients as defined by the American College of Cardiology and the American Heart Association guidelines, were more likely to receive the diagnostic procedure if they had fee-for-service coverage rather than coverage from a managed care plan (46 percent vs. 34 percent). Coronary angiography in such patients can lead to interventions that improve long-term health and reduce risk of death. "This is a significant statistical difference in care quality," says Guadagnoli. "Other studies have also found that patients with managed care received fewer procedures than their fee-for-service counterparts, but our study went a step further: It revealed a difference even when the procedure is highly recommended by current standards of care, which previous studies did not examine."
These findings also bear out the underuse of the procedure in general, as 66 percent of patients in managed care plans and 54 percent of patients with fee-for-service coverage did not receive the recommended standard of care for Class I patients. "These data show the need for increased adoption of this important diagnostic procedure in both types of patients," says Guadagnoli.
Among both groups of heart attack patients, the study found that where a patient was first admitted was crucial to having coronary angiography. A substantial underuse of coronary angiography was found when patients were admitted to hospitals without angiography facilities. Of those patients who needed coronary angiography, 85 percent of patients in managed care plans and 69 percent of patients with fee-for-service coverage did not receive the procedure while they were hospitalized for their heart attack. The patients who did receive the procedure were transferred to facilities with catheterization labs.
"A critical part of improving health care quality is understanding whether patients receive the services they need," says John M. Eisenberg, MD, director, Agency for Healthcare Research and Quality. "Future research should address the impact of different utilization management techniques on access to health care services as well as plan characteristics that may be responsible for differences among models of managed care."
Coronary angiography is an important diagnostic tool following a heart attack, as it can both improve treatment options and help reduce the risk of a second heart attack, which is nearly seven times more likely than in individuals who have never had a heart attack. This delicate procedure, done by cardiologists in catheterization labs, begins with the insertion of a thin guide wire through a small incision in the groin and into the major artery that carries blood from the heart to the leg. Guided by an imaging system, the wire and then a hollow catheter is led to the aorta and a network of coronary arteries that nourish the heart. A dye is inserted, which illuminates the region and defines the extent of the damage caused by the heart attack and any clogged sections that may lead to another attack—critical knowledge which can significantly improve treatment options and outcomes.
In addition to enrollment in a managed-care plan, increasing age was correlated with the underuse of angiography. Among patients assigned to Class I in both groups, the rate of angiography declined with increasing age, but a higher percentage of fee-for-service beneficiaries than managed-care enrollees underwent angiography in each age group.
The investigators believe more recent data will allow researchers to evaluate changes to these findings over time.
The study examined patient data records between February 1994 and July 1995. The Medicare managed care study population of 4,732 patients was drawn from 38 managed care plans in Florida, Texas, California, New York, Ohio, Pennsylvania, and Massachusetts by Health Care Financing Administration’s Cooperative Cardiovascular Project in collaboration with the General Accounting Office. These seven states account for over 70 percent of all Medicare beneficiaries enrolled in managed care. The Medicare fee-for-service study population of 46,321 patients was derived from the Cooperative Cardiovascular Project. Patients were classified according to the need for angiography by a panel of physicians using guidelines by the American College of Cardiology and the American Heart Association.
Edward Guadagnoli, PhD, and the study’s co-authors, Mary Beth Landrum, PhD, Harvard Medical School assistant professor of biostatistics, Eric Peterson, M. Phil, and Martin Gahart, PhD, at Health, Education, and Human Services Division, General Accounting Office, Thomas Ryan, MD, Department of Medicine, Boston University, and Barbara McNeil, MD, PhD, Harvard Medical School professor of health care policy, were funded by a grant from the Agency for Healthcare Research and Quality.
Journal
New England Journal of Medicine