Variations in Patterns of Care and Outcomes after Acute Myocardial Infarction for Medicare Beneficiaries in Fee-for-Service and HMO Settings

Background: Few contemporary studies examine trends in recurrent coronary heart disease (CHD) events and mortality following acute myocardial infarction (AMI). Therefore, we examined rates of mortality, recurrent AMI, and recurrent CHD events in the year following AMI overall and by race and sex in the national 5% random sample of Medicare beneficiaries. Methods: Beneficiaries were included if they were enrolled in traditional Medicare fee-for-service coverage (Parts A and B), were not enrolled in a Medicare Advantage plan, and experienced an index AMI (ICD9 410.xx except 410.x2) between January 1, 2001 and December 31, 2009. We used Poisson regression to calculate and examine linear changes in age-adjusted rates for all-cause mortality, recurrent AMI, and recurrent CHD events (defined as a hospitalization for AMI in the primary discharge diagnosis position, percutaneous coronary intervention, or coronary artery bypass graft surgery) during the 365 days following hospital discharge for the index AMI. To provide adequate sample size to investigate trends in outcomes by race-sex groups, we pooled calendar years into 3 time periods (2001-2003, 2004-2006, and 2007-2009). Results: Overall, 48,688 beneficiaries were included; 46% were men, 90% were white, and 7% were black. Changes in pooled 3 year rates for mortality, recurrent AMI, and recurrent CHD in the first year following an index AMI are shown in the table. Overall, we observed a -3.8% change in pooled 3 year age-adjusted rates for mortality, a -15.0% change in pooled 3 year age-adjusted rates for recurrent AMI, and a -11.1% change in pooled 3 year age-adjusted rates for recurrent CHD events. However, mortality following AMI decreased only in white men, and reductions in recurrent AMI or CHD occurred only for white men and women and black men but not black women. Conclusions: Despite the overall favorable trends in lower mortality and recurrent AMI and CHD events following an index AMI, more efforts in reducing disparities in CHD by race and sex are needed.

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Aspirin in the Treatment of Acute Myocardial Infarction in Elderly Medicare Beneficiaries

Circulation ◽

10.1161/01.cir.92.10.2841 ◽

1995 ◽

Vol 92 (10) ◽

pp. 2841-2847 ◽

Cited By ~ 109

Author(s):

Harlan M. Krumholz ◽

Martha J. Radford ◽

Edward F. Ellerbeck ◽

John Hennen ◽

Thomas P. Meehan ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Medicare Beneficiaries

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Timeliness and Quality of Care for Elderly Patients With Acute Myocardial Infarction Under Health Maintenance Organization vs Fee-for-Service Insurance

Archives of Internal Medicine ◽

10.1001/archinte.159.17.2013 ◽

1999 ◽

Vol 159 (17) ◽

pp. 2013 ◽

Cited By ~ 19

Author(s):

Stephen B. Soumerai ◽

Thomas J. McLaughlin ◽

Jerry H. Gurwitz ◽

Steven Pearson ◽

Cindy L. Christiansen ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Quality Of Care ◽

Elderly Patients ◽

Health Maintenance Organization ◽

Fee For Service ◽

Health Maintenance

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Abstract 058: Early Effect of Medicare Accountable Care Organizations on Acute Myocardial Infarction Episode Payments

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.058 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Shashank S Sinha ◽

Nicholas M Moloci ◽

Andrew M Ryan ◽

Brahmajee K Nallamothu ◽

John M Hollingsworth

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Accountable Care Organizations ◽

Accountable Care ◽

Medicare Beneficiaries ◽

Physician Services ◽

Post Discharge ◽

Early Effect ◽

Medicare Data ◽

The Difference

Objective: Spending for acute myocardial infarction (AMI) episodes varies widely across hospitals, driven primarily by payments made more than 30 days after discharge. Through collective incentives and an emphasis on care coordination, Medicare accountable care organizations (ACOs) may help reduce this variation. To test this hypothesis, we analyzed national Medicare data. Methods: Using a 20% random sample, we identified Medicare beneficiaries admitted for AMI from January 2010 to December 2013. We distinguished admissions to hospitals affiliated with a Medicare ACO from those that were not. We then calculated 90-day, price-standardized, risk-adjusted episode payments made on behalf of beneficiaries, differentiating between early (index admission to 30 days post-discharge) and late payments (31 to 90 days). We also calculated component payments, including those for the index hospitalization, readmissions, physician services, and post-acute care. Finally, we used difference-in-differences estimation to measure the effect of admission to an ACO-affiliated hospital on early and late episode payments. Results: Over the study period, 15,219 beneficiaries were admitted to 299 eventual ACO-affiliated hospitals and 73,910 were admitted to 1,685 never ACO-affiliated hospitals ( p <0.001). While beneficiaries admitted to eventual ACO-affiliated hospitals tended to be younger than those admitted to never ACO-affiliated hospitals (mean age: 79.2 ± 8.6 versus 80.0 ± 8.5, respectively; p =.003), they had similar levels of comorbidity (mean Elixhauser score: 2.7 ± 1.4 versus 2.7 ± 1.4, respectively; p =0.526). Mean 90-day episode payments were greater for ACO-affiliated hospitals [$24,887 versus $23,966; p <0.001]. In the period after ACO implementation (2012 and 2013), total payments for AMI episodes fell by $1259 (Figure; p <0.001). Most of this savings was attributable to decreases in early ($1118) versus late ($141) episode payments. However, none of these savings differed based on admission to an ACO-affiliated hospital ( p =0.363 for the difference). Conclusions: Early Medicare ACOs have not affected 90-day episode payments for AMI admissions. Future studies should explore the possibility of heterogeneity in effect based on ACO structure.

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