Quality of ambulatory care after myocardial infarction among medicare patients by type of insurance and region

PURPOSE: To evaluate use of effective cardiac medications and rehabilitation after myocardial infarction in the ambulatory setting in health maintenance organizations (HMOs) and fee-for-service care, and by region. SUBJECTS AND METHODS: We surveyed elderly Medicare patients during 1996 and 1997 in California (n = 516), Florida (n = 304), and the Northeast (n = 220; Massachusetts, New York, and Pennsylvania) approximately 18 months after myocardial infarction. We assessed use of cardiac medications and rehabilitation for HMO (n = 520) and fee-for-service (n = 520) patients matched by age, sex, month of infarct, and region. RESULTS: Across all regions, similar proportions of HMO and fee-for-service patients were using aspirin (72%, N = 374 vs. 74%, N = 387), beta-blockers (38%, N = 195 vs. 32%, N = 168), angiotensin-converting enzyme inhibitors (31%, N = 159 vs. 29%, N = 148), cholesterol-lowering agents (28%, N = 146 vs. 30%, N = 157), and calcium channel blockers (31%, N = 162 vs. 31%, N = 159; all P>0.07), except in California where more HMO patients received beta-blockers (36%, N = 93 vs. 26%, N = 66, P = 0.01). In adjusted analyses, use of these drugs did not differ significantly between HMO and fee-for-service patients. Substantial regional differences were evident in the use of beta-blockers (Northeast 46%, N = 102; Florida 34%, N = 102; California 31%, N = 159) and cholesterol-lowering agents (California 35%, N = 182; Florida 24%, N = 73; Northeast 22%, N = 48; each P <0.001). Fee-for-service patients were more likely than HMO patients to receive cardiac rehabilitation in unadjusted (32%, N = 167, vs. 22%, N = 141, P = 0.001) and adjusted analyses. CONCLUSIONS: Both HMO and fee-for-service patients would likely benefit from greater use of beta-blockers and cholesterol-lowering agents. Professional fees for cardiac rehabilitation may promote increased use among fee-for-service patients. Future studies should assess the quality of ambulatory cardiac care in different types of HMOs and the reasons for geographic variations in cardiac drug use.