医疗保险类型和地区对医疗保险患者心肌梗死后门诊护理质量的影响
Quality of ambulatory care after myocardial infarction among Medicare patients by type of insurance and region.
作者信息
Seddon M E, Ayanian J Z, Landrum M B, Cleary P D, Peterson E A, Gahart M T, McNeil B J
机构信息
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA.
出版信息
Am J Med. 2001 Jul;111(1):24-32. doi: 10.1016/s0002-9343(01)00741-0.
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.
目的
评估健康维护组织（HMO）和按服务收费医疗体系中，非卧床环境下心肌梗死后有效心脏药物的使用情况及康复情况，并按地区进行评估。
对象与方法
我们于1996年和1997年对加利福尼亚州（n = 516）、佛罗里达州（n = 304）以及东北部地区（n = 220；马萨诸塞州、纽约州和宾夕法尼亚州）的老年医疗保险患者进行了调查，调查时间为心肌梗死后约18个月。我们评估了年龄、性别、梗死月份和地区相匹配的HMO患者（n = 520）和按服务收费患者（n = 520）的心脏药物使用情况及康复情况。
结果
在所有地区，使用阿司匹林的HMO患者和按服务收费患者比例相似（72%，n = 374 对 74%，n = 387），使用β受体阻滞剂的比例相似（38%，n = 195 对 32%，n = 168），使用血管紧张素转换酶抑制剂的比例相似（31%，n = 159 对 29%，n = 148），使用降胆固醇药物的比例相似（28%，n = 146 对 30%，n = 157），使用钙通道阻滞剂的比例相似（（31%，n = 162 对 31%，n = 159；所有P>0.07），但在加利福尼亚州，接受β受体阻滞剂治疗的HMO患者更多（36%，n = 93 对 26%，n = 66，P = 0.01）。在调整分析中，HMO患者和按服务收费患者在这些药物的使用上没有显著差异。在β受体阻滞剂（东北部46%，n = 102；佛罗里达州34%，n = 102；加利福尼亚州31%，n = 159）和降胆固醇药物（加利福尼亚州35%，n = 182；佛罗里达州24%，n = 73；东北部22%，n = 48；各P<0.001）的使用上，地区差异明显。在未调整（32%，n = 167，对22%，n = 141，P = 0.001）和调整分析中，按服务收费患者比HMO患者更有可能接受心脏康复治疗。
结论
HMO患者和按服务收费患者都可能从更多使用β受体阻滞剂和降胆固醇药物中获益。心脏康复的专业费用可能会促使按服务收费患者更多地使用。未来的研究应评估不同类型HMO中非卧床心脏护理的质量以及心脏药物使用地理差异的原因。
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