title: Quality of ambulatory care after myocardial infarction among Medicare patients by type of insurance and region.
abstract: OBJECTIVE
  To evaluate use of effective cardiac medications and rehabilitation after myocardial infarction in the ambulatory setting in health maintenance organizations (HMOs) and fee-for-service care, and by region.
  
  
  METHODS
  We surveyed elderly Medicare patients during 1996 and 1997 in California (n = 516), Florida (n = 304), and the Northeast (n = 220; Massachusetts, New York, and Pennsylvania) approximately 18 months after myocardial infarction. We assessed use of cardiac medications and rehabilitation for HMO (n = 520) and fee-for-service (n = 520) patients matched by age, sex, month of infarct, and region.
  
  
  RESULTS
  Across all regions, similar proportions of HMO and fee-for-service patients were using aspirin (72%, n = 374 vs. 74%, n = 387), beta-blockers (38%, n = 195 vs. 32%, n = 168), angiotensin-converting enzyme inhibitors (31%, n = 159 vs. 29%, n = 148), cholesterol-lowering agents (28%, n = 146 vs. 30%, n = 157), and calcium channel blockers (31%, n = 162 vs. 31%, n = 159; all P >0.07), except in California where more HMO patients received beta-blockers (36%, n = 93 vs. 26%, n = 66, P = 0.01). In adjusted analyses, use of these drugs did not differ significantly between HMO and fee-for-service patients. Substantial regional differences were evident in the use of beta-blockers (Northeast 46%, n = 102; Florida 34%, n = 102; California 31%, n = 159) and cholesterol-lowering agents (California 35%, n = 182; Florida 24%, n = 73; Northeast 22%, n = 48; each P <0.001). Fee-for-service patients were more likely than HMO patients to receive cardiac rehabilitation in unadjusted (32%, n = 167, vs. 22%, n = 141, P = 0.001) and adjusted analyses.
  
  
  CONCLUSIONS
  Both HMO and fee-for-service patients would likely benefit from greater use of beta-blockers and cholesterol-lowering agents. Professional fees for cardiac rehabilitation may promote increased use among fee-for-service patients. Future studies should assess the quality of ambulatory cardiac care in different types of HMOs and the reasons for geographic variations in cardiac drug use.
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: M E
authors.initials: ME
authors.lastname: Seddon
authors.forename: J Z
authors.initials: JZ
authors.lastname: Ayanian
authors.forename: M B
authors.initials: MB
authors.lastname: Landrum
authors.forename: P D
authors.initials: PD
authors.lastname: Cleary
authors.forename: E A
authors.initials: EA
authors.lastname: Peterson
authors.forename: M T
authors.initials: MT
authors.lastname: Gahart
authors.forename: B J
authors.initials: BJ
authors.lastname: McNeil
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage; D000368:Aged; D000553:Ambulatory Care / Q000592:standards*; D000924:Anticholesteremic Agents / Q000008:administration & dosage; D001241:Aspirin / Q000008:administration & dosage; D002121:Calcium Channel Blockers / Q000008:administration & dosage; D002140:California / Q000453:epidemiology; D015897:Comorbidity; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D004522:Educational Status; D005006:Ethnicity / Q000706:statistics & numerical data; D018588:Fee-for-Service Plans / Q000592:standards*; D005260:Female; D005431:Florida / Q000453:epidemiology; D006279:Health Maintenance Organizations / Q000592:standards*; D006801:Humans; D007182:Income; D008297:Male; D006278:Medicare / Q000592:standards*; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control / Q000534:rehabilitation; D009511:New England / Q000453:epidemiology; D011787:Quality of Health Care; D011795:Surveys and Questionnaires; D014481:United States
chemical_list: D000319:Adrenergic beta-Antagonists; D000924:Anticholesteremic Agents; D002121:Calcium Channel Blockers; D001241:Aspirin