Cost-effectiveness of a coronary care unit versus an intermediate care unit for emergency department patients with chest pain.

BACKGROUND: Guidelines are not available for which patients with acute chest pain should be admitted to the coronary care unit and which patients can be reasonably triaged to monitored beds in lower levels of care. METHODS AND RESULTS: Clinical and resource utilization data from 12 139 emergency department patients with acute chest pain were used in a decision-analytic model to identify cost-effective guidelines for the admission to a coronary care unit versus an intermediate care unit for initially uncomplicated patients without other indications for intensive care. The probability of clinical complications and death were derived from data on age-specific subsets of the population. Resource utilization estimates were based on cost data from a subset of 901 patients and length of stay data for the entire cohort. The survival benefit associated with initial triage to the coronary care unit instead of an intermediate care unit was assumed to be 15%. In the baseline analysis for 55- to 64-year-old patients, the probability of acute myocardial infarction (AMI) at which the coronary care unit had an incremental cost-effectiveness below $50 000 per year-of-life-saved was 29%. Triage to the coronary care unit was somewhat more cost-effective in elderly patients because their higher early complication rate more than offset their shorter life expectancy. CONCLUSIONS: This analysis indicates that the coronary care unit usually should be reserved for patients with a moderate (21% or more, depending on the patient's age) probability of AMI unless patients need intensive care for other reasons. Clinical data suggest that only patients with ECG changes of ischemia or infarction not known to be old have a probability of AMI this high. Intermediate care units are appropriate for patients whose risks are not high enough for a coronary care unit to be cost-effective but too high for other alternatives to be recommended for safety and effectiveness.

Finding a lasting cure for U.S. health care.

In "Making Competition in Health Care Work" (July-August 1994), Elizabeth Olmsted Teisberg, Michael E. Porter, and Gregory B. Brown ask a question that has been absent from the national debate on health care reform: How can the United States achieve sustained cost reductions while at the same time maintaining quality of care? The authors argue that innovation driven by rigorous competition is the key to successful reform. A lasting cure for health care in the United States should include four basic elements: corrected incentives to spur productive competition, universal insurance to secure economic efficiency, relevant information to ensure meaningful choice, and innovation to guarantee dynamic improvement. In this issue's Perspectives section, eleven experts examine the current state of the health care system and offer their views on the shape that reform should take. Some excerpts: "On the road to innovation, let us not forget to develop the tools that allow physicians, payers, and patients to make better decisions." I. Steven Udvarhelyi; "Health care is not a product or service that can be standardized, packaged, marketed, or adequately judged by consumers according to quality and price." Arnold S. Relman; "Just as antitrust laws are the wise restraints that make competition free in other sectors of the economy, so the right kind of managed competition can work well in health care." Edward M. Kennedy "Biomedical research should be considered primarily an investment in the national economic well-being with additional humanitarian benefits." Elizabeth Marincola.

The effect of hospital financial characteristics on quality of care.

OBJECTIVE: To assess the relationship among hospital financial characteristics, patient payer mix, and the incidence of negligent medical injuries. DESIGN: Retrospective medical record review linked to hospital financial reports. SETTING: Acute care hospitals in New York State in 1984. POPULATION: Stratified, random sample of 30,195 medical records from 51 acute care hospitals. MAIN OUTCOME MEASURES: Hospital rates of medical injury and substandard care were developed from reviews of 30,195 medical records at 51 acute care hospitals in New York in 1984. Hospital-level variables representing financial status, hospital staffing, and the proportion of self-pay and Medicaid hospital discharges were compiled from a variety of secondary sources. RESULTS: The likelihood of negligent medical injury was highest in those hospitals with the lowest inpatient operating costs per hospital discharge (odds ratio, 2.8; 95% confidence interval, 1.5 to 5.5). The effect of low inpatient operating costs was marked among hospitals in financial distress, many of which served indigent populations. CONCLUSIONS: Patients admitted to hospitals that are unable to expend sufficient resources on patient care may be at higher risk of substandard care. Further study of the effect of hospital financial status on quality of care appears to be warranted.

Racial differences in the use of revascularization procedures after coronary angiography.

OBJECTIVE: To assess whether rates of coronary revascularization procedures differ between blacks and whites after coronary angiography is performed and to assess the relationship of these rates to hospital characteristics. DESIGN: A retrospective cohort study using 1987 and 1988 data on hospital claims and characteristics from the Health Care Financing Administration. SETTING: One thousand four hundred twenty-nine acute care hospitals that provide coronary angiography in the United States. PATIENTS: A national sample of 27,485 Medicare Part A enrollees, aged 65 to 74 years, who underwent inpatient angiography for coronary heart disease in 1987. MAIN OUTCOME MEASURE: The adjusted odds of revascularization with either coronary angioplasty or bypass graft surgery within 90 days of angiography for whites relative to blacks, controlling for age, sex, region, Medicaid eligibility, principal diagnosis, comorbid diagnoses, and hospital characteristics of ownership, teaching status, urban/suburban or rural location, and availability of revascularization procedures. RESULTS: White men and women were significantly more likely than black men and women, respectively, to receive a revascularization procedure after coronary angiography (57% and 50% vs 40% and 34%, both P < .001). The adjusted odds of receiving a revascularization procedure after coronary angiography were 78% higher for whites than blacks (95% confidence interval for odds ratio, 1.56 to 2.03). Statistically significant racial differences in the adjusted odds of receiving a revascularization procedure were present in all types of hospitals except rural hospitals, and these differences did not vary significantly by any of the four hospital characteristics (all P > .20 for interaction terms). CONCLUSIONS: Among Medicare enrollees, whites are more likely than blacks to receive revascularization procedures after coronary angiography. Racial differences of similar magnitude occur in all types of hospitals. These differences may reflect overuse in whites or underuse in blacks, but they are unlikely to reflect access to cardiologists or hospitals that perform revascularization procedures. Potential explanations include unmeasured clinical or socioeconomic factors, differing patient preferences, and racial bias at the hospitals performing angiography.

The effect of providing health coverage to poor uninsured pregnant women in Massachusetts.

OBJECTIVES: There has been substantial policy interest in whether the provision of health coverage to poor uninsured pregnant women affects access to prenatal care and birth outcomes. We therefore examined whether the statewide provision of health coverage to uninsured low-income pregnant women affects access to prenatal care and infant birth outcomes. DESIGN: Natural experiment. PATIENTS: All in-hospital, single-gestation live births in 1984 (N = 57,257) and 1987 (N = 64,346). INTERVENTION: In 1985, Massachusetts instituted Healthy Start, a program providing health coverage to uninsured pregnant women with incomes below 185% of the federal poverty level. MAIN OUTCOME MEASURES: Rates of satisfactory prenatal care, care initiated before the third trimester, and adverse infant outcome for uninsured women and for two concurrent control groups, women with Medicaid, and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. To assess the effect of the program, we examined the change in these interpayer differences in rates between 1984 and 1987. MAIN RESULTS: Between 1984 and 1987, the rate of satisfactory prenatal care declined from 96.4% to 93.8% for all women in Massachusetts (P < .001). There was no statewide change in the overall incidence of adverse birth outcome (6.6% in both years). In 1984, uninsured women were less likely than privately insured women to receive satisfactory prenatal care (90.5% and 98.1%, respectively; interpayer difference, -7.6%) and to initiate care before the third trimester (94.2% and 99.1%; interpayer difference, -4.9%), and were more likely to suffer an adverse birth outcome (7.1% and 5.8%; interpayer difference, 1.3%). Between 1984 and 1987, there were no statistically significant changes in the interpayer differences in rates for any of the outcome measures relative to either control group. CONCLUSIONS: Our findings suggest that access to prenatal care may have declined for all women in Massachusetts between 1984 and 1987. In the setting of this statewide decline in access, the expansion of health coverage to uninsured low-income pregnant women was not associated with an improvement in access to prenatal care or birth outcomes.

Acute myocardial infarction in the Medicare population. Process of care and clinical outcomes.

OBJECTIVE: To describe the process of care and clinical outcomes associated with acute myocardial infarction (AMI) in the Medicare population, and to examine differences in process of care and outcome of care as a function of patient age, gender, and race. DESIGN: Retrospective cohort study using a longitudinal database created from Medicare utilization and administrative files. PATIENT POPULATIONS: A cohort of AMI patients covered by Medicare in 1987 and a random sample of Medicare patients without AMI. MAIN PROCESS AND OUTCOME MEASUREMENTS: (1) The use of coronary angiography, coronary artery bypass graft surgery, and percutaneous transluminal coronary angioplasty during the first 90 days after a new AMI; (2) mortality at 30 days, 1 year, and 2 years; (3) reinfarction rates; and (4) reoperation rates for coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty. MAIN RESULTS: Mortality rates were high: 26% at 30 days, 40% at 1 year, and 47% at 2 years. They varied greatly by age, less so by gender and race, and were high even among patients who survived the first 30 days. Compared with mortality, reinfarction was uncommon, occurring in 7.3% of patients. During the first 90 days, 23% of all patients underwent angiography and 13% underwent coronary revascularization (coronary artery bypass graft surgery, 8%; percutaneous transluminal coronary angioplasty, 5%). The use of all three procedures decreased with age and was less common among women and blacks than among men and whites. Differential use by age and race was greater for angiography than for revascularization procedures. CONCLUSIONS: The prognosis following AMI in patients aged 65 years and above is much worse than is commonly realized. Procedure use in these patients varies as a function of gender and race, even though mortality does not. Further research is needed to reduce the mortality of elderly patients with AMI and to understand the significance of differences in procedure use on the basis of sociodemographic characteristics.

Cost-effectiveness and cost-benefit analyses in the medical literature. Are the methods being used correctly?

OBJECTIVE: To determine whether published cost-effectiveness and cost-benefit analyses have adhered to basic analytic principles. DESIGN: Structured methodologic review of published articles. STUDY SAMPLE: Seventy-seven articles published either from 1978 to 1980 or from 1985 to 1987 in general medical, general surgical, and medical subspecialty journals. MAIN OUTCOME MEASUREMENTS: Articles were reviewed to assess the use and reporting of six fundamental principles of analysis. These principles were derived by reviewing widely cited textbooks and articles describing the methods for performing economic analyses and by selecting the methods universally recommended. MAIN RESULTS: Overall performance was only fair. Three articles adhered to all six principles, and the median number of principles to which articles adhered was three. Among the problems noted were failure to make underlying assumptions explicit and, therefore, verifiable, and failure to test assumptions with sensitivity analyses. No improvement in performance was observed between 1978 and 1987. Articles in general medical journals, however, were more likely to use analytic methods appropriately than articles in the general surgical or medical subspecialty literature. CONCLUSIONS: Greater attention should be devoted to ensuring the appropriate use of analytic methods for economic analyses, and readers should make note of the methods used when interpreting the results of economic analyses.

Determinants of resource utilization for patients admitted for evaluation of acute chest pain.

OBJECTIVE: To identify determinants of resource utilization among patients with suspected acute myocardial infarction. DESIGN: Prospective cohort study, with prospective collection of detailed clinical data and retrospective collection of nonclinical data and resource utilization data. SETTING: Urban, tertiary-care, teaching hospital. PATIENT POPULATION: 992 consecutive patients over the age of 30 years, admitted from the emergency department for evaluation of acute chest pain unexplained by obvious trauma or chest roentgenographic abnormality, were eligible for the study. After excluding patients who had left against medical advice, who had been transferred to another hospital, or who had incomplete utilization data, 903 patients were included in the analyses. MEASUREMENTS AND OUTCOMES: The authors evaluated the effects of 22 clinical and nonclinical factors on resource use. Resource use was primarily evaluated by length of stay; charges were evaluated in secondary analyses. RESULTS: In the entire study population, increased length of stay was associated with a diagnosis of acute myocardial infarction or angina, severity of complications, use of invasive and noninvasive testing, and initial triage to the coronary care unit. In the 424 (47%) patients who had had completely uncomplicated courses after admission, high coefficients of variability were found for length of stay (0.88) and for total charges (0.78). In these uncomplicated patients, increased length of stay was associated with the use of noninvasive cardiac testing (66% longer for patients undergoing echocardiography or radionuclide ventriculography, and 46% longer for patients undergoing exercise tests or ambulatory arrhythmia monitoring), initial triage to the coronary care unit (23% longer), admission at the end of the week (21% longer), and insurance coverage other than Blue Cross/Blue Shield or a commercial carrier (21% for self-pay, 25% for Medicaid, and 48% for Medicare). CONCLUSIONS: These findings indicate that after adjustment for important clinical factors, nonclinical factors had a significant impact on length of stay among a large group of uncomplicated patients. Interventions aimed at reducing logistic difficulties in the performance of noninvasive testing and decreasing the number of low-risk patients who are triaged to coronary care unit beds may decrease resource utilization.

Comparison of the quality of ambulatory care for fee-for-service and prepaid patients.

OBJECTIVE: To determine whether the quality of care for common ambulatory conditions is adversely affected when physicians are provided with incentives to limit the use of health services. DESIGN: Retrospective cohort study over a 2-year period. SETTING: Four group practices that cared for both fee-for-service patients and prepaid patients within a network model health maintenance organization (HMO). PATIENTS: Equal numbers of prepaid (HMO) and fee-for-service patients were selected by randomly choosing medical records from each group practice: 246 patients with chronic uncomplicated hypertension and 250 women without chronic diseases who received preventive care. MAIN OUTCOME MEASURES: Adequate hypertension control was defined as a mean blood pressure of less than 150/90. Adequate preventive care was defined as the provision of blood pressure screening, colon cancer screening, breast cancer screening, and cervical cancer screening within guidelines recommended by the 1989 U.S. Preventive Services Task Force. Resource use was measured by the annual number of visits and tests. MAIN RESULTS: The adjusted relative odds of HMO patients having controlled hypertension, compared with fee-for-service patients, were 1.82 (95% CI, 1.02 to 3.27). The relative risks of HMO patients receiving preventive care within established guidelines were 1.19 (CI, 0.93 to 1.51) for colon cancer screening, 1.78 (CI, 1.11 to 2.84) for annual breast examinations, 1.75 (CI, 1.08 to 2.84) for biannual mammography, and 1.35 (CI, 1.13 to 1.60) for Papanicolaou smears every 3 years. Prepaid patients had visit rates that were 18% to 22% higher than those of fee-for-service patients. CONCLUSIONS: In the type of network model HMO we studied, the quality and quantity of ambulatory care for HMO patients was equal to or better than that for fee-for-service patients. In this setting, the incentives for physicians to limit resource use may be offset by lack of disincentives for HMO patients to seek care.

Teaching status and resource use for patients with acute myocardial infarction: a new look at the indirect costs of graduate medical education.

To investigate whether the process of graduate medical education increases costs in teaching hospitals by causing longer lengths of stay and greater resource use, we compared lengths of stay, hospital charges, and the use of cardiovascular procedures for patients with acute myocardial infarction admitted to the teaching and nonteaching services of a university-affiliated community hospital. After adjusting for severity of illness and demographic characteristics, patients on the teaching services had a mean length of stay that was shorter by 0.6 days (p = 0.04) and mean charges that were $2,060 lower (p = 0.15) than for patients on the nonteaching service. Patients on the teaching service also had 15 percent (95% CI: -26, -4) fewer cardiac catheterizations and 9 percent (-18, 0) fewer procedures for myocardial revascularization (angioplasty or cardiac bypass surgery). These findings suggest that graduate medical education per se may not directly increase the use of health care resources and that the cost differences between teaching and nonteaching hospitals may be largely a consequence of other factors. These factors may include epiphenomena of teaching such as a specialized organizational structure, specialized patient care services, and continuing medical education for the nursing and medical staffs. They may also include factors not related to teaching such as differences in patients' severity of illness and sociodemographic characteristics.