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Heart Disease

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Study finds no differences in heart attack followup care provided to Medicare fee-for-service and HMO patients, but effective drugs are underprescribed for both

Type of Medicare coverage may make no difference when it comes to the likelihood that elderly beneficiaries seen by doctors for care following a heart-attack will receive effective treatment, according to a new study supported by the Agency for Healthcare Research and Quality (HS09718). Findings reported by a team of Harvard Medical School researchers indicate that patients in Medicare's traditional fee-for-service program were approximately just as likely as those in Medicare HMOs to be prescribed three drugs proven effective for improving the survival of older patients who have had heart attacks—beta blockers, which slow the heart rate and prevent abnormal heart rhythms; ACE inhibitors, which improve heart function; and cholesterol-lowering drugs, which reduce atherosclerosis.

Furthermore, although the researchers were unable to say what percentages of the patients should have received these medications, the usage rates of beta blockers and cholesterol-lowering drugs were low—about a third of the patients were prescribed them. This is about the same percentage that were given calcium channel blockers, which are less effective but continue to be prescribed. These low rates indicate that there are significant opportunities for improving the quality of post-acute myocardial infarction care for both Medicare fee-for-service and HMO patients.

Estimates from the National Health and Nutrition Examination Survey suggest that at least 53 percent of men and 64 percent of women age 65 and older with coronary artery disease have low-density lipoprotein levels that would benefit from cholesterol-lowering therapy. Also, randomized trials of beta blockers that included elderly heart attack patients indicate that elderly patients may benefit more than younger patients from these drugs.

The researchers also found no major differences in the percentages of patients in both types of Medicare plans who were told by their doctors to exercise more and/or quit smoking. The only significant difference was that the traditional Medicare patients were referred more often to cardiac rehabilitation programs, possibly because of professional fees for this service under fee-for-service care.

When the researchers studied elderly Medicare patients as a whole, they found several unexplained regional differences among patients who lived in either the Northeast, California, or Florida. Those in Northeastern States were prescribed beta blockers and ACE inhibitors more often than were Medicare patients in California or Florida, but they were less likely to be given drugs to lower their cholesterol levels. According to the study's leaders, John Z. Ayanian, M.D., and Barbara J. McNeil, M.D., Ph.D., these variations suggest the need for tailoring educational efforts to the geographic area.

The study findings are based on interviews conducted in 1996 and 1997 with roughly 1,000 Medicare patients aged 65 and older approximately 18 months after discharge from a hospital for heart attack.

For more information, see "Quality of ambulatory care after myocardial infarction among Medicare patients by type of insurance and region," by Mary E. Seddon, M.B., Ch.B., M.P.H., Dr. Ayanian, Mary Beth Landrum, Ph.D., and others, in the July 8, 2001, American Journal of Medicine 111(1), pp. 24-32.

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