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Payer status appears to have a strong influence on hospital management of patients with heart attack

Use of acute reperfusion therapies, invasive procedures, and hospital length of stay vary among hospitalized heart attack patients, depending on their insurance. These are the findings of a recent study that was supported in part by the Agency for Healthcare Research and Quality (HS08843). The study found that utilization was greatest for patients who were covered by Medicare or commercial insurers, intermediate for the uninsured and those covered under managed care, and least for Medicaid patients.

Despite differences in use of hospital resources, there was no significant difference in hospital-adjusted mortality rates among the commercially insured, Medicare patients 65 and older, and HMO patients. However, it's not clear whether the less aggressive use of medical resources contributed to the higher mortality rates among the uninsured and Medicaid patients, notes the study's lead author John G. Canto, M.D., M.S.P.H., of the University of Alabama Medical Center at Birmingham.

The researchers examined the influence of payer status on use of hospital resources by the more than 332,000 AMI patients who were enrolled in the National Registry of Myocardial Infarction 2 study from 1994 to 1996. Medicare and Medicaid recipients tended to be sicker and to have higher rates of diabetes, hypertension, prior AMI and congestive heart failure, and more severe heart failure. These two groups also tended to be poorer and to include a higher proportion of women than privately insured groups.

After adjusting for these important factors, Medicare recipients were as likely as commercially insured patients to receive acute reperfusion treatments, coronary angiography, or subsequent coronary revascularization (angioplasty or bypass surgery). On the other hand, Medicaid patients, HMO patients, and the uninsured were the least likely to undergo coronary angiography, and Medicaid recipients and the uninsured were the least likely to receive subsequent coronary revascularization compared with the commercial group, after controlling for baseline differences. Hospital stays were longest for Medicare and Medicaid groups, which were more likely to include older women with more chronic diseases and in-hospital complications requiring prolonged care.

More details are in "Payer status and the utilization of hospital resources in acute myocardial infarction," by Dr. Canto, William J. Rogers, M.D., William J. French, M.D., and others, in the March 27, 2000, Archives of Internal Medicine 160, pp. 817- 823.

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