ORLANDO, Nov. 12 -- The odds of surviving a heart attack may have as much to do with a patient's health insurance policy as the hospital to which the heart attack victim is rushed or whether a cardiologist treats the patient, according to a new study presented today at the American Heart Association's 70th Scientific Sessions.
A review of nearly 4,000 hospitalized heart attack patients under 65 years of age found that health maintainance organization (HMO) members were almost twice as likely to die while hospitalized than those who were treated under more traditional insurance plans, says Paul N. Casale, M.D., of the Lancaster Heart Foundation. HMO enrollment was a significant predictor of death in the study of heart attack patients under age 65 admitted to southeastern Pennsylvania hospitals in 1993.
One quarter of the participants in the study belonged to HMOs, while the others were covered under fee-for-service plans. The participants were a subset of a much larger state-wide review by the Pennsylvania Health Care Cost Containment Council.
"We chose to look at patients admitted to hospitals in Philadelphia and the surrounding suburbs because managed-care coverage was already fairly advanced there by 1993," Casale says. "Also, it is important to note that these were heart attack patients under age 65 who were non-Medicare, non-Medicaid insured."
After taking into consideration the type of hospital, the individual hospital, and whether the patient was treated by a cardiologist or primary care physician, the increased risk for death for HMO members was 2.16. "This is roughly twice the rate of deaths than fee-for-service patients," he reports.
While there was little difference in overall heart surgery rates between the two groups -- 15.7 percent vs. 15.6 percent -- HMO patients were less likely to have received either cardiac catheterization or percutaneous transluminal coronary angioplasty (PTCA).
In cardiac catheterization, a narrow tube, or catheter, is placed in a patient's heart through a major artery in the arm or leg. Physicians then test the interior blood pressure of the heart chambers and surrounding blood vessels. In PTCA, a catheter carrying a small balloon is inserted into coronary heart arteries through the patient's skin. The balloon is then repeatedly inflated and deflated to compress the blockage that obstructs blood flow to the heart.
Seventy-nine percent of patients under fee-for-service plans had catheterization compared to 70 percent of HMO members. Similarly, 33 percent received PTCA compared to 27 percent of HMO patients. Both procedures are widely used, respectively, to determine heart function and increase oxygen delivery to the heart after a heart attack. Although fewer HMO patients received either procedure, it was not clear what role, if any, managed-care policies played in treatment decisions or in patient deaths overall, according to the study.
"We don't clearly know the reason why," says Casale. "Other studies have found differences in rates of angioplasty and catheterization, but after the data were analyzed they found that more HMO patients had gone to hospitals that did not provide the procedures. Once they controlled for this, there was no difference."
The differences in survival and use rates of cardiac catheterization and PTCA found in our study suggest the need for further research," he says.
The study's co-authors were Jayne L. Jones, M.P.H., Flossie E. Wolf, M.S., and Yanfen Pei, M.S., of the Pennsylvania Health Care Cost Containment Council in Harrisburg, PA. and L. Marlin Eby, Ph.D., of Messiah College in Grantham, PA.
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