Online Coverage from the
70th Annual Scientific Sessions
of the American Heart Association
November 9 - November 12, 1997
© 1997 Medscape, Inc.
In-Hospital Mortality is Higher in AMI Patients Enrolled in an
Speaker: Paul N. Casale, MD
Reporter: Carlos S. Ince, MD
The healthcare system in the US has undergone dramatic changes in the
There has been a concerted effort to control the cost of healthcare,
and a number of techniques have been initiated to attain this goal.
In this effort, critical pathways have been established to
cost-effectively manage a variety of patient care issues by
Health maintenance organizations (HMOs) control their costs by using
a number of strategies, including limiting admissions and referrals,
and reducing utilization rates of procedures.
There is concern that these restrictive guidelines may adversely
effect clinical outcomes.
The intent of this analysis was to compare the clinical outcomes base
d on insurance type (HMO versus fee-for-service) after controlling
for 12 patient characteristics predictive of in-hospital mortality,
as well as for physician specialty (cardiology versus primary care
providers), hospital type (those with and without the ability to
perform bypass surgery), and individual hospital variability.
Dr. Paul Casale and colleagues of Lancaster Heart Foundation in
Lancaster, Pennsylvania, analyzed 3999 acute myocardial infarction
(AMI) patients under the age of 65 who were admitted to hospitals in
southeastern Pennsylvania in 1993. These patients were a subset of
those taking part in The Pennsylvania Health Care Cost Containment
Council (PHCCCC) analysis of 20 clinical variables in patients with
AMI. That study aimed to identify independent predictors of mortality.
Of the 20 patient characteristics examined, 12 variables were found
to be significant predictors -- the same 12 that were controlled for
in this trial.
The analysis was conducted on 1034 HMO patients and 2965
fee-for-service patients. Most data were collected from the
clinical database, and additional data were extracted from patient
records, when appropriate. Fee-for-service patients were slightly
older (54 versus 53 years of age), were more likely to be male
(78% versus 75%), and were more likely to have cardiac dysrhythmias
or conduction abnormalities. The groups were similar with respect to
the percentage of comorbidities and prognostic factors, including
cardiogenic shock, cardiomyopathy, diabetes mellitus, hemodialysis,
renal failure, infarct location, and prior history of coronary artery
HMO Patients Fared Worse
Multivariate analysis revealed that in-hospital mortality was
significantly higher for HMO patients than in fee-for-service patients
(odds ratio 2.16, 95% CI; 1.24 to 3.76) after adjusting for physician
specialty, hospital type, and individual hospital. Univariate
analysis on procedure utilization demonstrated that fee-for-service
patients were more likely to undergo cardiac catheterization (79%
versus 70%, P<0.001) and percutaneous transluminal
coronary angioplasty (33% versus 27%, P=0.007). There was
no difference in the rates of bypass surgery in the groups (15.7%
versus 15.6%). When adjusted for patient risk, physician specialty,
and hospital type, HMO patients were less likely to have a cardiac
catheterization (odds ratio 0.65, 95% CI; 0.52 to 0.82).
Based on these data, enrollment in an HMO is an independent
predictor of in-hospital mortality in those patients presenting with
an AMI. HMO patients are less likely than fee-for-service patients
to undergo cardiac catheterization and angioplasty after acute
infarct. Further studies are needed to determine the specific
policies of managed care organizations which may be contributing to
adverse clinical outcomes.
AHA Scientific Sessions
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