title: Appropriateness of coronary angiography after myocardial infarction among Medicare beneficiaries. Managed care versus fee for service.
abstract: BACKGROUND
  Previous studies have documented that cardiac procedures are performed less frequently in patients enrolled in managed-care plans than in those with fee-for-service coverage. However, it is not known whether this difference is due to less frequent use of cardiac procedures when they are indicated or to less frequent use when they are not indicated.
  
  
  METHODS
  We compared the use of coronary angiography after acute myocardial infarction among Medicare beneficiaries who had traditional fee-for-service coverage with the use among Medicare beneficiaries enrolled in managed-care plans. The analysis was adjusted for differences in demographic and clinical characteristics of the patients and for characteristics of the hospitals to which they were admitted. We studied more than 50,000 beneficiaries in seven states and evaluated their care according to guidelines proposed by the American College of Cardiology and the American Heart Association (ACC-AHA).
  
  
  RESULTS
  Among the 44 percent of patients in both groups who had ACC-AHA class I indications (those for which angiography is useful and effective), more fee-for-service beneficiaries than managed-care enrollees underwent angiography (46 percent vs. 37 percent, P<0.001). The rate of angiography was very low among patients with class I indications who were admitted to hospitals without angiography facilities (31 percent in the fee-for-service group and 15 percent in the managed-care group, P<0.001). Among patients with class III indications (those for which angiography is not effective), the rate of use was low in both groups (approximately 13 percent).
  
  
  CONCLUSIONS
  In situations in which angiography is thought to be useful, it is used less often among Medicare beneficiaries enrolled in managed-care plans than among those with fee-for-service coverage. Moreover, rates of use among patients with class I indications are fairly low in both groups, suggesting that there is room for improving the care of elderly patients with myocardial infarction, especially those admitted to hospitals without angiography facilities.
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA 02115-5899, USA. guadagnoli@hcp.med.harvard.edu
authors.forename: E
authors.initials: E
authors.lastname: Guadagnoli
authors.forename: M B
authors.initials: MB
authors.lastname: Landrum
authors.forename: E A
authors.initials: EA
authors.lastname: Peterson
authors.forename: M T
authors.initials: MT
authors.lastname: Gahart
authors.forename: T J
authors.initials: TJ
authors.lastname: Ryan
authors.forename: B J
authors.initials: BJ
authors.lastname: McNeil
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017023:Coronary Angiography / Q000706:statistics & numerical data*; D018588:Fee-for-Service Plans / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008329:Managed Care Programs / Q000706:statistics & numerical data*; D006278:Medicare; D009203:Myocardial Infarction / Q000145:classification / Q000000981:diagnostic imaging*; D014481:United States