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A growing number of hospitals have sophisticated cardiac services such as coronary angiography, coronary angioplasty, and coronary artery bypass graft (CABG) surgery to diagnose and treat heart attack patients. At the same time, cost and insurance pressures have resulted in shorter hospital stays for heart attack victims, resulting in the need for more post-discharge rehabilitative services. Two recent studies that were supported in part by the Agency for Healthcare Research and Quality (HS08071, principal investigator Barbara J. McNeil, M.D., Ph.D., of Harvard Medical School) examined these issues as they relate to elderly heart attack patients.
The first study found that the availability of sophisticated cardiac procedures at hospitals may increase their use but not necessarily patient survival. The second study revealed that over one-third (37 percent) of elderly heart attack patients received post-acute services within 30 days of discharge, with three-fourths of them using home health care. The studies are described here.
Dendukuri, N., Normand S.T., and McNeil, B.J. (2003, February). "Impact of cardiac service availability on case-selection for angiography and survival associated with angiography." Health Services Research 38(1), pp. 21-40.
According to this study, elderly heart attack patients for whom angiography was deemed of uncertain benefit were far more likely to undergo angiography at hospitals that offered it. They were even more likely to undergo the procedure at hospitals that offered both angiography and revascularization (coronary angioplasty or bypass surgery). But surprisingly, patients treated at hospitals with angiography and/or revascularization, even those deemed to need angiography, had no better survival than those treated at hospitals that offered no cardiac services, according to Dr. Dendukuri and her colleagues.
The investigators analyzed data from the Cooperative Cardiovascular Project database on 37,788 elderly Medicare heart attack patients discharged from hospitals in seven U.S. States in 1994 and 1995, as well as Medicare claims files and provider files. They compared the relative risk of receiving angiography for various patients, hospital characteristics, and 1-year survival rates among patients at hospitals with no cardiac services, angiography services only, or angiography and revascularization services.
Angiography permits x-ray visualization of the heart and blood vessels following injection of a contrast dye to diagnose heart damage. Coronary angioplasty involves threading of a catheter into a heart vessel and inflating the tip of the catheter to flatten one or more plaques against coronary arterial walls to open up cardiac blood flow. In CABG surgery, a prosthesis or a section of a blood vessel is grafted onto one of the coronary arteries to bypass a blockage in a coronary artery.
Compared with patients for whom angiography was deemed necessary, the relative risk of receiving angiography among those for whom it was deemed of uncertain benefit was 0.58, 0.79, and 0.92 at hospitals offering no cardiac services, angiography only, and angiography and revascularization, respectively. However, there was no significant difference in survival following angiography across hospital types, both overall as well as within clinical need categories.
These findings indicate that while there is a beneficial effect of receipt of angiography on 1-year survival, the size of this benefit is the same regardless of hospital availability of cardiac services. Because of the consistent improved survival associated with angiography and the increased use of angiography at hospitals with on-site cardiac facilities, the findings from this study suggest that patients should be triaged to hospitals with these capabilities.
Bronskill, S.E., Normand, S.T., and McNeil, B.J. (2002, Winter). "Post-acute service use following acute myocardial infarction in the elderly." Health Care Financing Review 24(2), p. 77-93.
Pressures for shortened hospital stays for heart attack patients have increased the need for post-acute services (PAS) to aid patients' recuperation and rehabilitation after hospital discharge. For instance, this study found that 37 percent of elderly Medicare heart attack patients received PAS within 30 days of discharge, with three-fourths of them using home health care. In addition, 11.6 percent used a skilled nursing facility, 11.9 percent used multiple facilities, 1.5 percent used a rehabilitation facility, and 0.4 percent used a long-term care hospital.
Compared with other heart attack patients, patients whose illness was more severe were nearly three times as likely (odds ratio, OR 2.85) to receive PAS. Those discharged from for-profit hospitals were 23 percent more likely (OR 1.23) to receive PAS, and patients discharged from hospitals that provided home health services through the hospital or a subsidiary were 15 percent more likely (OR 1.15) to receive PAS. For-profit hospitals may be more effective at discharge planning and implementing appropriate rehabilitative strategies. Alternatively, they may be more likely to respond to financial pressures to reduce hospital stays than not-for-profit hospitals, resulting in premature discharges that necessitate more PAS use, conclude the researchers.
The differences in PAS use between States persisted, even after accounting for many patient and hospital characteristics. Patients from Ohio and Texas were less likely to receive PAS than patients from Pennsylvania, Florida, New York, and Massachusetts.
These findings are based on analysis of the Cooperative Cardiovascular Project database, Medicare administrative data, and American Hospital Association data. The researchers examined the impact of patient, hospital, and State factors on PAS use among 39,837 elderly Medicare patients who were discharged following a heart attack from 1,500 hospitals in seven States.
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