Outcomes of acute myocardial infarction in the Department of Veterans Affairs: does regionalization of health care work?

OBJECTIVES: This study examines the association between the regional availability of cardiac technology and outcomes of care for patients admitted to Department of Veterans Affairs (VA) hospitals. Patients using the VA regional medical system initially are admitted to a hospital with or without the on-site availability of technology-intensive cardiac services. METHODS: The authors identified male veterans (n = 24,229) discharged from VA hospitals with a primary diagnosis of acute myocardial infarction (AMI) from January 1, 1988 through December 31, 1990. Analyses of mortality up to 2 years after AMI and the use of cardiac procedures were stratified by the type of VA hospitals to which patients initially were admitted. Logistic regression models adjusted for age, race, marital status, hospitalization in previous year, comorbidities, cardiac complications coded, and year of AMI. RESULTS: Adjusted mortality was significantly higher for patients initially admitted to hospitals without on-site cardiac technology at: 2 days (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.62-0.81), 90 days (OR 0.78; 95% CI 0.73-0.85); 1 year (OR 0.87, 95% CI 0.81-0.93); and 2 years (OR 0.86, 95% CI 0.81-0.92) compared with hospitals with on-site cardiac technology (ie, coronary angioplasty and cardiac surgery facilities). Patients initially admitted to hospitals without on-site cardiac technology also were less likely to undergo cardiac procedures than patients admitted to hospitals with on-site cardiac technology. CONCLUSIONS: The regional distribution of cardiac technology may restrict patient access to technology-intensive services and to "equally good medical care." Policies that promote regionalization of medical services should consider carefully the distribution of benefits and burdens to patients.

Where do elderly veterans obtain care for acute myocardial infarction: Department of Veterans Affairs or Medicare?

OBJECTIVE: To examine Department of Veterans Affairs (VA) and Medicare hospitalizations for elderly veterans with acute myocardial infarction (AMI), their use of cardiac procedures in both systems, and patient mortality. DATA SOURCES: Merging of inpatient discharge abstracts obtained from VA Patient Treatment Files (PTF) and Medicare MedPAR Part A files. STUDY DESIGN: A retrospective cohort study of male veterans 65 years or older who were prior users of the VA medical system (veteran-users) and who were initially admitted to a VA or Medicare hospital with a primary diagnosis of AMI at some time from January 1, 1988 through December 31, 1990 (N = 25,312). We examined the use of cardiac catheterization, coronary bypass surgery, and percutaneous transluminal coronary angioplasty in the 90 days after initial admission for AMI in both VA and Medicare systems, and survival at 30 days, 90 days, and one year. Other key measures included patient age, race, marital status, comorbidities, cardiac complications, prior utilization, and the availability of cardiac technology at the admitting hospital. PRINCIPAL FINDINGS: More than half of veteran-users (54 percent) were initially hospitalized in a Medicare hospital when they suffered an AMI. These Medicare index patients were more likely to receive cardiac catheterization (OR 1.24, 95% C.I. 1.17-1.32), coronary bypass surgery (OR 2.01, 95% C.I. 1.83-2.20), and percutaneous transluminal coronary angioplasty (OR 2.56, 95% C.I. 2.30-2.85) than VA index patients. Small proportions of patients crossed over between systems of care for catheterization procedures (VA to Medicare = 3.3%, and Medicare to VA = 5.1%). Many VA index patients crossed over to Medicare hospitals to obtain bypass surgery (27.6 percent) or coronary angioplasty (12.1 percent). Mortality was not significantly different between veteran-users who were initially admitted to VA versus Medicare hospitals. CONCLUSIONS: Dual-system utilization highlights the need to look at both systems of care when evaluating access, costs, and quality either in VA or in Medicare systems. Policy changes that affect access to and utilization of one system may lead to unpredictable results in the other.

Angina patients' ratings of current health and health without angina: associations with severity of angina and comorbidity.

OBJECTIVE: To investigate the relationship between chronic stable angina patients' ratings of two health states (current health and health free of angina), the difference between these two ratings (the "anticipated gain"), and measures of anginal severity and comorbidity. DESIGN: Cross-sectional interviews and questionnaires. SETTING: Out-patient clinics and medical inpatient service of a Veterans Affairs Medical Center. PARTICIPANTS: Patients with chronic stable angina with no prior history of a revascularization procedure attending clinic appointments (n = 44) or electively admitted for cardiac catheterization (n = 11). Measurements. Ratings of current health and health free of angina using a verbal rating scale in which 0 = death and 100 = perfect health, the MOS SF-36, the Index of Coexistent Disease (a validated measure of comorbidity), and a question on the severity of anginal symptoms. RESULTS: Mean (95% CI) rating of current health was 61.8 (59.2, 64.4) and that of health free of angina was 77.0 (74.5, 79.5). Median anticipated gain between the two health ratings was 10.0 (range 0-80). Correlations between ratings for both health states and subscales of the SF-36 were positive, with some reaching statistical significance. In regression models with rating of current health, rating of life without angina, and anticipated gain as the dependent variables, severity of comorbidity was highly significant in all three, whereas severity of angina was significant only in the current-health rating model. Severity of comorbidity had much greater explanatory power in all three models than did severity of angina. CONCLUSIONS: Severity of comorbidity was a better predictor of patients' current health rating, rating for angina-free health, and anticipated gain from relief of angina than was severity of angina. Since patient perceptions of a symptom may be distinct from self-reported symptom severity, treatment-outcome studies should assess patient preferences in addition to symptom severity. Comorbidity should also be measured in such studies. Having patients rate current health and symptom-free health may be a useful measure of treatment effectiveness for specific symptoms in clinical trials and patient care, and may help patients and clinicians prioritize multiple health problems.

Refractory hypoxemia in inferior myocardial infarction from right-to-left shunting through a patent foramen ovale: a case report and review of the literature.

Right ventricular (RV) infarction is a well-recognized complication of some acute inferior myocardial infarctions. Recently, there have been numerous case reports of RV infarctions complicated by severe refractory hypoxemia secondary to right-to-left shunting through a patent foramen ovale. An additional case missed by transthoracic echocardiography and cardiac catheterization is reported and the English literature on the subject is reviewed.

Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs.

OBJECTIVE: To examine whether blacks admitted to Veterans Affairs Medical Centers (VAMCs) with an acute myocardial infarction (AMI) are less likely than whites to undergo cardiac catheterization or coronary revascularization procedures and to determine the impact of these differences on patient survival. DESIGN: A retrospective observational study of inpatient discharge abstracts from the Veterans Health Administration (VHA). SETTING: All one hundred fifty-eight acute care hospitals in the VHA. PATIENT POPULATION: Male veterans (n = 33,641) discharge from VAMCs with an International Classification of Diseases, Ninth Revision, Clinical Modification code for AMI from January 1, 1988, to December 31, 1990. INTERVENTION: None. MAIN OUTCOME MEASURES: The use of cardiac catheterization, coronary angioplasty, and/or bypass surgery in the 90 days after admission for AMI, and survival at 30 days, 1 year, and 2 years. MAIN RESULTS: Adjusting for patient and hospital characteristics, blacks with an AMI were 33% less likely than whites to undergo cardiac catheterization, 42% less likely to receive coronary angioplasty, and 54% less likely to receive coronary bypass surgery. Among patients who underwent catheterization, blacks were also less likely than whites to have a subsequent cardiac revascularization procedure. Adjusted 30-day survival for blacks was significantly greater than for whites. One- and 2-year survival rates after AMI were not significantly different between blacks and whites. CONCLUSIONS: In a health care system designed to provide equivalent availability of care to all eligible patients, blacks received substantially fewer cardiac procedures after AMI than whites. Despite undergoing fewer interventional procedures, blacks had better short-term and equivalent intermediate survival rates compared with whites.

Smoking cessation following admission to a coronary care unit.

OBJECTIVE: To determine the impact of an episode of serious cardiovascular disease on smoking behavior and to identify factors associated with smoking cessation in this setting. DESIGN: Prospective observational study in which smokers admitted to a coronary care unit (CCU) were followed for one year after hospital discharge to determine subsequent smoking behavior. SETTING: Coronary care unit of a teaching hospital. PATIENTS: Preadmission smoking status was assessed in all 828 patients admitted to the CCU during one year. The 310 smokers surviving to hospital discharge were followed and their smoking behaviors assessed by self-report at six and 12 months. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Six months after discharge, 32% of survivors were not smoking; the rate of sustained cessation at one year was 25%. Smokers with a new diagnosis of coronary heart disease (CHD) made during hospitalization had the highest cessation rate (53% vs. 31%, p = 0.01). On multivariate analysis, smoking cessation was more likely if patients were discharged with a diagnosis of CHD, had no prior history of CHD, were lighter smokers (less than 1 pack/day), and had congestive heart failure during hospitalization. Among smokers admitted because of suspected myocardial infarction (MI), cessation was more likely if the diagnosis was CHD than if it was noncoronary (37% vs. 19%, p less than 0.05), but a diagnosis of MI led to no more smoking cessation than did coronary insufficiency. CONCLUSION: Hospitalization in a CCU is a stimulus to long-term smoking cessation, especially for lighter smokers and those with a new diagnosis of CHD. Admission to a CCU may represent a time when smoking habits are particularly susceptible to intervention. Smoking cessation in this setting should improve patient outcomes because cessation reduces cardiovascular mortality, even when quitting occurs after the onset of CHD.