Public Release: 

It Matters Where, In America, You Suffer A Heart Attack

Duke University

NEW ORLEANS -- Where you live in America helps determine how a doctor treats your heart attack, how long you stay in the hospital, and whether you are likely to need further hospitalization in the next few months, researchers said Tuesday (Nov. 12) at the annual meeting of the American Heart Association.

Duke University Medical Center researchers used detailed medical, economic, and quality-of-life information for more than 2,300 patients across the United States to paint a picture of what regional differences exist in the treatment of heart attacks. They looked at both the initial hospitalization of these patients during 1990-1993, and they tracked what happened to them up to one year later.

They found that the rates of death and second heart attacks were almost the same across the country, but that the use of interventional procedures and hospital stays varied widely, more than they expected. "The contrasts were quite striking, including some large differences in efficiency that we did not expect, as well as some we anticipated," said Eric Eisenstein, who specializes in economic analysis at the Duke Clinical Research Institute.

He said that, based on the new data, the Mid-Atlantic region was the most expensive region in treating heart attacks through one year of follow-up, and that the Mountain and Pacific states, where managed care was reputedly more widespread during the study period, rated the best for both the initial hospitalization and up to a year later.

"This could upset prevailing views in several ways," said Duke cardiologist Dr. Daniel Mark, who oversaw the analysis. "Northeastern hospitals have always been held up as the most cost-efficient, but early studies concentrated on the use of invasive cardiac procedures during the initial hospitalization. The picture changes when you look at what actually happens to a patient over the span of a year.

"We found evidence of a patient management strategy on the West Coast that seems to strike the best balance between cost and patient outcomes," Mark said. "It combines quick decisions about use of interventions, a moderate use of those procedures and fewer hospital days. How much this is due to the influence of more managed care in that part of the country, we can't say."

After dividing the country into U.S. census regions, the researchers found the areas that have the greatest contrast are: New England states (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut), the Mid-Atlantic region (New York, New Jersey, and Pennsylvania), South Central states (Texas, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, and Oklahoma), Pacific states (Alaska, Hawaii, Washington, Oregon, California) and the Mountain states (Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah and Nevada).

They specifically discovered that:

  • During their initial hospitalization, heart attack patients in New England and Mid-Atlantic states were given fewer diagnostic catheterizations and invasive therapies, such as angioplasties or heart bypass surgery (half as many as some areas), but they stayed in the hospital longer than patients in any other part of the country. Patients also were more likely to be readmitted to the hospital for follow-up treatments during the next six months.
For the Mid-Atlantic region, year-long medical expenses cost an average of more than $26,000. The longer length of initial hospitalization may be due to the fact that it took cardiologists a day longer to decide to give their patients a diagnostic catheterization compared to the Pacific region, Eisenstein said.
  • In South Central states, there was a very high rate of aggressive care during initial hospitalization (twice as much as some areas) with high initial costs, but lower need to readmit patients compared to any other region. In the South Central states, the average tab for year-long care was $25,261. Interventional procedures accounted for almost 30 percent of the bill.
  • The lowest costs for 12 months of heart attack care belonged to the Pacific states, at $21,635. "They were doing far better because they seemed to have a balanced approach to resource utilization," said Eisenstein. Hospitals and physicians in these states offered a moderate use of aggressive procedures, and the shortest length of stay in the hospital (7.6 days, compared to 11.2 days in the Mid-Atlantic).
The detailed cost data used in the analysis came from a random sample of the 22,043 U.S. patients who were enrolled in GUSTO, a large international trial that tested two different clot-busting drugs. The sample represents "real world cardiology," Eisenstein said. Physicians in the GUSTO trial were not given guidelines on how to treat their patients during the study, he said. He added that patients were treated both at major medical centers and community hospitals.

Eisenstein and Mark said the bottom-line messages of the study are:

  • It is possible to reduce cost of care for acute heart attack patients without increasing complications or bad outcomes.
  • Minimizing costs in the short-run may result in increased costs later on follow-up. "Managed care and other health care payers often focus on short-term big-ticket costs like those related to the use of cardiac catheterization and angioplasty," Mark said. "This study shows that judging the balance between costs and quality of care requires a longer-term perspective."
South Central Mountain Mid-Atlantic Pacific New England
1. initial cath 86 % 69 % 65 % 62 % 47 %
2. cath by 6 months 6 % 14 % 17 % 11 % 19 %
3. initial PCTA, CABG 46 % 28 % 24 % 29 % 20 %
4. PCTA, CABG by 6 months 9 % 14 % 16 % 16 % 15 %
5. length of stay initial hosp. 10 days 8.8 days 11.2 days 7.6 days 10.6 days
6. cost- initial hospital $21,891 $17,931 $21,417 $17,102 $19,710
7. cost- total $25,261 $22,621 $26,454 $21,635 $24,363
8. % total cost of procedures 29.9 % 22 % 18.1 % 22 % 14.2 %

  1. The percentage of patients who were given a diagnostic catheterization during their first (initial) hospitalization following a heart attack. A catheterization is given to assess the extent of heart disease in a patient and to help a physician tailor further treatment.

  2. The percentage of patients who were readmitted for a catheterization during the six months following their initial admission. This includes patients who received a catheterization during the initial hospitalization.

  3. The percentage of patients given an angioplasty (PCTA) or bypass surgery (CABG) during their initial hospitalization.

  4. The percentage of patients who were readmitted for angioplasty or bypass surgery during the six months following their intial admission. This includes patients who received angioplasty or bypass surgery during the initial hospitalization.

  5. The average number of days patients stayed in the hospital the first time they were admitted.

  6. Average costs of care (hospital and physician) during the initial hospitalization.

  7. Average costs of care (hospital and physician) during the initial hospitalization and for readmissions occurring during the subsequent year.

  8. Percentage of initial costs of care (hospital and physician) that is due to invasive cardiac procedures (catheterization, angioplasty and/or bypass surgery).

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