Quality of ambulatory care after myocardial infarction among Medicare patients by type of insurance and region.
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.
Seddon
M E
ME
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA.
Ayanian
J Z
JZ
Landrum
M B
MB
Cleary
P D
PD
Peterson
E A
EA
Gahart
M T
MT
McNeil
B J
BJ
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
D000319:Adrenergic beta-Antagonists; D000924:Anticholesteremic Agents; D002121:Calcium Channel Blockers; D001241:Aspirin