Abstract
Background: Prior studies have suggested that in‐hospital availability may be an important determinant for the use of invasive cardiac services; however, whether this association is influenced by payer status remains unclear.
Hypothesis: The interaction of payer status and the on‐site availability of coronary arteriography is associated with increased utilization of this procedure.
Methods: In‐hospital availability and utilization of coronary arteriography was ascertained in 275,046 patients with acute myocardial infarction (AMI) enrolled in the National Registry of Myocardial Infarction 2 from June 1994 to April 1996. Logistic regression analyses were performed to determine the association between the on‐site availability of cardiac catheterization at the initial hospital and subsequent utilization of coronary arteriography. Similar analyses were performed within Medicare, Medicaid, Commercial, Health Maintenance Organization (HMO), and Uninsured payer groups.
Results: Patients initially admitted to hospitals having on‐site cardiac catheterization facilities were almost twice as likely to receive coronary arteriography as patients admitted to hospitals without such facilities and later transferred out [un‐adjusted odds ratio (OR) = 1.69,95% confidence interval (CI) 1.66–1.73, p < 0.0001; adjusted OR = 2.08,95% CI 2.01–2.15, p < 0.0001]. Furthermore, this relationship of increased utilization with greater availability was evident within each payer group, but was highest among those with Commercial insurance and lowest among Medicaid recipients: [Commercial insurance (OR = 2.19,95% CI 2.07–2.31, p < 0.0001); Uninsured (OR = 1.74,95% CI 1.57–1.92, p < 0.0001); HMO (OR = 1.67,95% CI 1.54–1.82, p < 0.0001); Medicare 1.60,95% CI 1.55–1.64, p < 0.0001); Medicaid (1.46,95% CI 1.29–1.65, p < 0.0001)].
Conclusions: Our results show a strong association between in‐hospital availability and subsequent utilization of invasive cardiac procedures following AMI among all patients, but the strength of these associations varied among payer status.
Keywords: acute myocardial infarction, coronary arteriography, health insurance, payer status
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References
- 1. Schartz WB: The inevitable failure of current cost‐containment strategies. J Am Med Assoc 1987; 257: 220–224 [PubMed] [Google Scholar]
- 1. National Center for Health Statistics : Detailed Diagnoses and Procedures, National Hospital Discharge Survey, 1993. Vital and Health Statistics. Series 13. No. 122. Washington, D.C.: Government Printing Office, 1995. (DHHS publication no. (PHS) 95–1783 [PubMed] [Google Scholar]
- 3. Every NR, Larson EB, Litwin PE, Maynard C, Fihn SD, Eisenberg MS, Hallstrom AP, Martin JS, Weaver WD: The association between on‐site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. N Engl J Med 1993; 329: 546–551 [DOI] [PubMed] [Google Scholar]
- 4. Blustein J: High‐technology cardiac procedures: The impact of service availability on service use in New York state. J Am Med Assoc 1993; 270: 344–349 [DOI] [PubMed] [Google Scholar]
- 5. Pilote L, Califf RM, Sapp S, Miller DP, Mark DB, Weaver WD, Gore JM, Armstrong PW, Ohman EM, Topol EJ: Regional variation across the United States in the management of acute myocardial infarction. N Engl J Med 1995; 333: 565–572 [DOI] [PubMed] [Google Scholar]
- 6. Pilote L, Miller DP, Califf RM, Rao JS, Weaver WD, Topol EJ: Determinants of the use of coronary angiography and revascularization after thrombolysis for acute myocardial infarction. N Engl J Med 1996; 335: 1198–1205 [DOI] [PubMed] [Google Scholar]
- 6. American Hospital Association : Hospital Statistics 95/96: Emerging Trends in Hospitals, the AHA Profile of US Hospitals, 1995.
- 8. Rogers WJ, Bowlby LJ, Chandra NC, French WJ, Gore JM, Lambrew CT, Rubison M, Tiefenbrunn AJ, Weaver WD: Treatment of myocardial infarction in the United States (1990 to 1993): Observations from the National Registry of Myocardial Infarction. Circulation 1994; 90: 2103–2114 [DOI] [PubMed] [Google Scholar]
- 9. Wasted health care dollars. Consumer Reports, 1992: 435–448
- 10. Ryan TJ, Anderson JL, Antman EM, Braniff BA, Brooks NH: ACC/AHA guidelines for the management of patients with acute myocardial infarction. J Am Coll Cardiol 1996; 28: 1328–1428 [DOI] [PubMed] [Google Scholar]
- 11. Brodie B, Grines CL, Spain M, Griffin J, Balestrini C, Stone GW, Costantini C, Esente P, Ayres M, Nobuyoshi M, Donohue B, Chelliah N, Rothbaum D, Wharton T, Jones D, Mason D, Sachs D O'Neill WW: A prospective, randomized trial evaluating early discharge (day 3) without non‐invasive risk stratification in low risk patients with AMI: PAMI‐2 (abstr). J Am Coll Cardiol 95; 901–1: 5A [Google Scholar]
- 12. Every NR, Parsons LS, Fihn SD, Larson EB, Maynard C, Hallstrom AP, Martin JS, Weaver WD: Long‐term outcome in acute myocardial infarction patients admitted to hospitals with and without on‐site cardiac facilities. Circulation 1997; 96: 1770–1775 [DOI] [PubMed] [Google Scholar]
- 13. Sada MJ, French WJ, Carlisle DM, Chandra NC, Gore JM, Rogers WJ: Comparison of HMO and fee‐for‐service utilization of angiography and in‐hospital mortality in patients with acute myocardial infarction. J Am Coll Cardiol 1998; 31: 1474–1480 [DOI] [PubMed] [Google Scholar]
- 14. Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy SD, Noether M: Frequency and costs of diagnostic imaging in office practice—a comparison of self‐referring and radiologist‐referring physicians. N Engl J Med 1990; 323: 1604–1608 [DOI] [PubMed] [Google Scholar]
- 15. Tussig AD, Wojtowycz MA: Physician‐induced demand by Irish GP's. Soc Sci Med 1986; 9: 851–860 [DOI] [PubMed] [Google Scholar]
- 16. Rice TH, Labell RJ: Do physicians induce demand for medical services? J Health Polit Policy Law 1989; 14: 587–600 [DOI] [PubMed] [Google Scholar]
- 17. Bunker JP: Surgical manpower: A comparison of operations and surgeons in the United States and in England and Wales. N Engl J Med 1970; 282: 135–144 [DOI] [PubMed] [Google Scholar]
- 18. Golberg KC, Hartz AJ, Jacobson SJ, Krakauer H, Rimm AA: Racial and community factors influencing coronary artery bypass graft surgery rates for all 1986 Medicare patients. J Am Med Assoc 1992; 267: 1473–1477 [PubMed] [Google Scholar]
- 18. Mitchell JB, Cromwell J: Variation in surgery rates and the supply of surgeons In Regional Variations in Hospital Use (Ed. Rothberg DL.), p. 103–129. Lexington, Mass.: DC Heath, 1982. [Google Scholar]
- 20. Shain M, Roemer MI: Hospital costs relate to the supply of beds. Mod Hosp 1959; 92 (4): 71–74 [PubMed] [Google Scholar]