Guadagnoli E, Landrum M B, Peterson E A, Gahart M T, Ryan T J, McNeil B J
Department of Health Care Policy, Harvard Medical School, Boston, MA 02115-5899, USA.
N Engl J Med. 2000 Nov 16;343(20):1460-6. doi: 10.1056/NEJM200011163432006.
Previous studies have documented that cardiac procedures are performed less frequently in patients enrolled in managed-care plans than in those with fee-for-service coverage. However, it is not known whether this difference is due to less frequent use of cardiac procedures when they are indicated or to less frequent use when they are not indicated.
We compared the use of coronary angiography after acute myocardial infarction among Medicare beneficiaries who had traditional fee-for-service coverage with the use among Medicare beneficiaries enrolled in managed-care plans. The analysis was adjusted for differences in demographic and clinical characteristics of the patients and for characteristics of the hospitals to which they were admitted. We studied more than 50,000 beneficiaries in seven states and evaluated their care according to guidelines proposed by the American College of Cardiology and the American Heart Association (ACC-AHA).
Among the 44 percent of patients in both groups who had ACC-AHA class I indications (those for which angiography is useful and effective), more fee-for-service beneficiaries than managed-care enrollees underwent angiography (46 percent vs. 37 percent, P<0.001). The rate of angiography was very low among patients with class I indications who were admitted to hospitals without angiography facilities (31 percent in the fee-for-service group and 15 percent in the managed-care group, P<0.001). Among patients with class III indications (those for which angiography is not effective), the rate of use was low in both groups (approximately 13 percent).
In situations in which angiography is thought to be useful, it is used less often among Medicare beneficiaries enrolled in managed-care plans than among those with fee-for-service coverage. Moreover, rates of use among patients with class I indications are fairly low in both groups, suggesting that there is room for improving the care of elderly patients with myocardial infarction, especially those admitted to hospitals without angiography facilities.
先前的研究表明，参加管理式医疗计划的患者接受心脏手术的频率低于享受按服务收费保险的患者。然而，尚不清楚这种差异是由于在有手术指征时心脏手术的使用频率较低，还是在无手术指征时使用频率较低。
我们比较了享受传统按服务收费保险的医疗保险受益人与参加管理式医疗计划的医疗保险受益人在急性心肌梗死后冠状动脉造影的使用情况。分析对患者的人口统计学和临床特征差异以及他们所入住医院的特征进行了调整。我们研究了七个州的50,000多名受益人，并根据美国心脏病学会和美国心脏协会（ACC - AHA）提出的指南评估了他们的治疗情况。
在两组中符合ACC - AHA I类指征（造影有用且有效的指征）的44%的患者中，接受造影的按服务收费受益人多于参加管理式医疗计划的受益人（46%对37%，P<0.001）。入住没有造影设备医院的I类指征患者的造影率非常低（按服务收费组为31%，管理式医疗组为15%，P<0.001）。在有III类指征（造影无效的指征）的患者中，两组的使用率都很低（约13%）。
在造影被认为有用的情况下，参加管理式医疗计划的医疗保险受益人接受造影的频率低于享受按服务收费保险的受益人。此外，两组中I类指征患者的使用率都相当低，这表明改善老年心肌梗死患者的治疗，尤其是入住没有造影设备医院的患者的治疗，仍有空间。
