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Coronary angiography is underused for both Medicare managed care and fee-for-service heart attack patients

According to a just-published study, Medicare patients enrolled in managed care plans are significantly less likely than those with traditional Medicare fee-for-service coverage to receive needed coronary angiography—a potentially lifesaving diagnostic procedure—following a heart attack, even though the procedure is a highly recommended practice. The study was supported by the Agency for Healthcare Research and Quality (HS08071) and led by Edward Guadagnoli, Ph.D., associate professor at Harvard Medical School's Department of Health Care Policy.

Nearly one-fifth of the Medicare population is in a managed-care plan. As these numbers have increased, there has been a decline in the growth of overall medical expenditures. This is cause for concern about the quality of care provided to managed-care enrollees, and particularly the elderly who are the most vulnerable patients, notes Dr. Guadagnoli. He and his colleagues found that the elderly heart attack patients who needed coronary angiography—or Class I patients as defined by the American College of Cardiology and the American Heart Association guidelines—were more likely to receive the diagnostic procedure if they had fee-for-service coverage rather than coverage through a managed care plan (46 percent vs. 34 percent). This is a significant statistical difference in care quality, according to Dr. Guadagnoli.

Other studies have also found that patients with managed care received fewer procedures than their fee-for-service counterparts, but this study went a step further. It revealed a difference even when the procedure was highly recommended by current standards of care, a factor not examined in previous studies.

These findings also bear out the underuse of the procedure in general, as 66 percent of patients in managed care plans and 54 percent of patients with fee-for-service coverage did not receive the recommended standard of care for Class I patients. Among both groups of heart attack patients, the study found that where a patient was first admitted was crucial to having coronary angiography. A substantial underuse of coronary angiography was found when patients were admitted to hospitals without angiography facilities. Of those patients who needed coronary angiography, 85 percent of patients in managed care plans and 69 percent of patients with fee-for-service coverage did not receive the procedure while they were hospitalized for their heart attack. The patients who did receive the procedure were transferred to facilities with catheterization labs.

Increasing age also was correlated with the underuse of angiography. Among patients assigned to Class I in both coverage groups, the rate of angiography declined with increasing age, but a higher percentage of fee-for-service beneficiaries than managed-care enrollees underwent angiography in each age group. The investigators believe more recent data will allow researchers to evaluate changes to these findings over time.

In commenting on the new study, AHRQ Director John Eisenberg, M.D., noted that a critical part of improving health care quality is understanding whether patients are receiving the services they need. Dr. Eisenberg points out that future research should address the impact of different utilization management techniques on access to health care services, as well as plan characteristics that may be responsible for differences among models of managed care.

The study examined patient data records between February 1994 and July 1995. The Medicare managed care study population of 4,732 patients was drawn from 38 managed care plans in Florida, Texas, California, New York, Ohio, Pennsylvania, and Massachusetts. These seven States account for over 70 percent of all Medicare beneficiaries enrolled in managed care. The Medicare fee-for-service study population of 46,321 patients was derived from the Cooperative Cardiovascular Project. Patients were classified according to the need for angiography by a panel of physicians using guidelines by the American College of Cardiology and the American Heart Association.

For more information, see "Appropriateness of coronary angiography after myocardial infarction among Medicare beneficiaries: Managed care versus fee for service," by Dr. Guadagnoli, Mary Beth Landrum, Ph.D., Eric A. Peterson, M.Phil., and others, in the November 16, 2000, New England Journal of Medicine 343, pp. 1460-1466.

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