Person:

McLaughlin, Thomas

Objectives. —To study determinants and adverse outcomes (mortality and rehospitalization) of β-blocker underuse in elderly patients with myocardial infarction; and whether the relative risks (RRs) of survival associated with β-blocker use were comparable to those reported in the large randomized controlled trials (RCTs).

Setting. —New Jersey Medicare population.

Design. —Retrospective cohort design using linked Medicare and drug claims data from 1987 to 1992.

Patients. —Statewide cohort of 5332 elderly 30-day acute myocardial infarction (AMI) survivors with prescription drug coverage, of whom 3737 were eligible for β-blockers.

Main Outcome Measures. —β-Blocker and calcium channel blocker use in the first 90 days after discharge and mortality rates and cardiac hospital readmissions over the 2-year period after discharge, controlling for sociodemographic and baseline risk variables.

Results. —Only 21% of eligible patients received β-blocker therapy; this rate remained unchanged from 1987 to 1991. Patients were almost 3 times more likely to receive a new prescription for a calcium channel blocker than for a new β-blocker after their AMIs. Advanced age and calcium channel blocker use predicted underuse of β-blockers. Controlling for other predictors of survival, the mortality rate among β-blocker recipients was 43% less than that for nonrecipients (RR=0.57; 95% confidence interval [CI], 0.47-0.69). Effects on mortality were substantial in all age strata (65-74 years, 75-84 years, and ≥85 years) and consistent with the results for elderly subgroups of 2 large RCTs. β-Blocker recipients were rehospitalized 22% less often than nonrecipients (RR=0.78; 95% CI, 0.67-0.90). Use of a calcium channel blocker instead of a β-blocker was associated with a doubled risk of death (RR=1.98; 95% CI, 1.44-2.72), not because calcium channel blockers had a demonstrable adverse effect, but because they were substitutes for β-blockers.

Conclusions. —β-Blockers are underused in elderly AMI survivors, leading to measurable adverse outcomes. These data suggest that the survival benefits of β-blockade after an AMI may extend to eligible patients older than 75 years, a group that has been excluded from RCTs.

AT THE TIME of this report, approximately 5 million Medicare patients received care from capitated health maintenance organizations (HMOs), representing a 360% increase from 1991; this number is expected to grow to more than 12 million by 2005.1 A common perception is that economic incentives in HMOs may reduce the speed and provision of urgent, essential care, especially in vulnerable patients like the elderly.2- 4 Unfortunately, there are virtually no data showing how the rapid shift to managed care may be affecting the quality of acute care for elderly patients.5,6

Some organizational processes and incentives in HMOs may raise the quality of care for acute conditions, while others may lower quality. For example, large HMOs often have 24-hour telephone triage systems and patient education to encourage patients with acute conditions to use emergency transportation to the hospital. Health maintenance organizations may also be more likely to establish quality-improvement systems (eg, treatment protocols or clinical pathways).7 Finally, HMOs are more likely to employ younger physicians, who may have more up-to-date knowledge about the safety and efficacy of newer drug treatments.8,9

On the other hand, in efforts to contain costs, primary care gatekeepers in HMOs attempt to reduce the inappropriate use of emergency departments, specialty care, and hospital care. Conceivably, this might result in delays in approval of the necessary use of ambulances and emergency departments. DeMaria et al4 have also expressed concern that such gatekeepers might reduce access to appropriate specialty care in emergency conditions.

The treatment of acute myocardial infarction (AMI) provides an ideal model for studying the quality of acute care for elderly HMO patients. Cardiovascular disease is the leading cause of disability and death in the elderly; 80% of all deaths caused by AMI occur in those aged 65 years or older.10 Strong evidence from large randomized clinical trials shows that early treatment with aspirin, thrombolytic agents, and β-blockers increases the rate of survival among elderly patients with AMI.11- 16 Because the benefits of treatment with thrombolytics decline rapidly within 6 hours after initial symptom onset,17 the time from symptom onset to hospital presentation is an important determinant of survival. Unfortunately, elderly patients with AMI are more likely to have atypical symptoms, delayed hospital presentation,18 and less frequent use of thrombolytic, β-blocker, and aspirin therapy.19

In this study, we reviewed the medical records of 2304 elderly patients admitted with AMI at 20 urban community hospitals in Minnesota to compare the quality of emergency care under HMO vs FFS insurance coverage. Specifically, we compared the use of emergency transportation, treatment delay (≥6 hours), time to electrocardiogram (ECG), use of drug treatments known to reduce morbidity and mortality in eligible patients with AMI (aspirin, thrombolytics, and β-blockers), and time from hospital arrival to thrombolytic administration (door-to-needle time). Unlike previous investigations,5 we attempted to identify specific mechanisms that might explain any observed insurance-related differences in quality of care, such as use of specialists.

BACKGROUND. Many state Medicaid programs limit the number of reimbursable medications that a patient can receive. We hypothesized that such limitations may lead to exacerbations of illness or to admissions to institutions where there are no caps on drug reimbursements. METHODS. We analyzed 36 months of Medicaid claims data from New Hampshire, which had a three-drug limit per patient for 11 of those months, and from New Jersey, which did not. The study patients in New Hampshire (n = 411) and a matched comparison cohort in New Jersey (n = 1375) were Medicaid recipients 60 years of age or older who in a base-line year had been taking three or more medications per month, including at least one maintenance drug for certain chronic diseases. Survival (defined as remaining in the community) and time-series analyses were conducted to determine the effect of the reimbursement cap on admissions to hospitals and nursing homes. RESULTS. The base-line demographic characteristics of the cohorts were nearly identical. In New Hampshire, the 35 percent decline in the use of study drugs after the cap was applied was associated with an increase in rates of admission to nursing homes; no changes were observed in the comparison cohort (RR = 1.8; 95 percent confidence interval, 1.2 to 2.6). There was no significantly increased risk of hospitalization. Among the patients in New Hampshire who regularly took three or more study medications at base line, the relative risk of admission to a nursing home during the period of the cap was 2.2 (95 percent confidence interval, 1.2 to 4.1), and the risk of hospitalization was 1.2 (95 percent confidence interval, 0.8 to 1.6). When the cap was discontinued after 11 months, the use of medications returned nearly to base-line levels, and the excess risk of admission to a nursing home ceased. In general, the patients who were admitted to nursing homes did not return to the community. CONCLUSIONS. Limiting reimbursement for effective drugs puts frail, low-income, elderly patients at increased risk of institutionalization in nursing homes and may increase Medicaid costs.

Background Prior authorization is a popular, but understudied, strategy for reducing medication costs. We evaluated the impact of a controversial prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes among dual Medicaid and Medicare enrollees with a Social Security Disability Insurance designation of permanent disability.

Methods We linked Medicaid and Medicare (2000-2003) claims for dual enrollees in Michigan and a comparison state, Indiana. Using interrupted time-series and longitudinal data analysis, we estimated the impact of the policy on antidepressant medication use, treatment initiation, disruptions in therapy, and adverse health events among continuously enrolled (Michigan, n = 28 798; Indiana, n = 21 769) and newly treated (Michigan, n = 3671; Indiana, n = 2400) patients.

Results In Michigan, the proportion of patients starting nonpreferred agents declined from 53% prepolicy to 20% postpolicy. The prior authorization policy was associated with a small sustained decrease in therapy initiation overall (9 per 10 000 population; P = .007). We also observed a short-term increase in switching among established users of nonpreferred agents overall (risk ratio, 2.88; 95% confidence interval, 1.87-4.42) and among those with depression (2.04; 1.22-3.42). However, we found no evidence of increased disruptions in treatment or adverse events (ie, hospitalization, emergency department use) among newly treated patients.

Conclusions Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users. However, unintended effects on treatment initiation and switching among patients already taking the drug were also observed, lending support to the state's previous decision to discontinue prior approval for antidepressants in 2003.

Background The rapid expansion of managed care in the United States has increased debate regarding the appropriate mix of generalist and specialist involvement in medical care.

Objective To compare the quality of medical care when generalists and cardiologists work separately or together in the management of patients with acute myocardial infarction (AMI).

Methods We reviewed the charts of 1716 patients with AMI treated at 22 Minnesota hospitals between 1992 and 1993. Patients eligible for thrombolytic aspirin, β-blockers, and lidocaine therapy were identified using criteria from the 1991 American College of Cardiology guidelines for the management of AMI. We compared the use of these drugs among eligible patients whose attending physician was a generalist with no cardiologist input, a generalist with a cardiologist consultation, and a cardiologist alone.

Results Patients cared for by a cardiologist alone were younger, presented earlier to the hospital, were more likely to be male, had less severe comorbidity, and were more likely to have an ST elevation of 1 mm or more than generalists' patients. Controlling for these differences, there was no variation in the use of effective agents between patients cared for by a cardiologist attending physician and a generalist with a consultation by a cardiologist. However, there was a consistent trend toward increased use of aspirin, thrombolytics, and β-blockers in these patients compared with those with a generalist attending physician only (P<.05 for β-blockers only). Differences between groups in the use of lidocaine were not statistically significant. The adjusted probabilities of use of thrombolytics for consultative care and cardiologist attending physicians were 0.73 for both. Corresponding probabilities were 0.86 and 0.85 for aspirin and 0.59 and 0.57 for β-blockers, respectively.

Conclusions For patients with AMI, consultation between generalists and specialists may improve the quality of care. Recent policy debates that have focused solely on access to specialists have ignored the important issue of coordination of care between generalist and specialist physicians. In hospitals where cardiology services are available, generalists may be caring for patients with AMI who are older and more frail. Future research and policy analyses should examine whether this pattern of selective referral is true for other medical conditions.

THE RAPID expansion of managed care in the United States has increased public and scientific debate regarding the appropriate mix of generalist and specialist involvement in medical care. Previous research suggests that cardiologists have better knowledge than generalists concerning efficacious therapies in the treatment of acute myocardial infarction (AMI).1 However, previous studies2 also suggest that there is little relationship between knowledge or self-reported practice and actual behavior. Despite intense controversy, few studies3 exist comparing the care provided to comparable patients by generalists and specialists.

The focus on comparative performance of generalists and specialists ignores opportunities for sharing of knowledge and experience through formal and informal consultation. In 1 study,4 the quality of psychoactive drug prescribing in nursing homes was highest among generalists who reported frequent consultations with psychiatrists. A recent study5 of a US health maintenance organization showed that an intervention fostering collaborative care between generalists and psychiatrists improved adherence to antidepressant regimens, patient satisfaction, and other outcomes in patients with major depression.

In contrast to previous studies1,6,7 that used survey data to measure differences between generalist and specialist care, we investigated differences in quality of care actually provided to patients with AMI when generalists and cardiologists work separately and in consultation. Quality of care was defined as care consistent with nationally recognized evidence-based practice guidelines. Specifically, we examined the use of drugs known to reduce morbidity and mortality in eligible patients (aspirin, thrombolytics, and β-blockers),8- 11 and nonindicated use of lidocaine, which may cause increased mortality.12 We compared use of these drugs among patients whose attending physician was (1) a generalist with no cardiologist input, (2) a generalist with cardiologist consultation, and (3) a cardiologist.

Context.— The effectiveness of recruiting local medical opinion leaders to improve quality of care is poorly understood.

Objective.— To evaluate a guideline-implementation intervention of clinician education by local opinion leaders and performance feedback to (1) increase use of lifesaving drugs (aspirin and thrombolytics in eligible elderly patients, β-blockers in all eligible patients) for acute myocardial infarction (AMI), and (2) decrease use of a potentially harmful therapy (prophylactic lidocaine).

Design.— Randomized controlled trial with hospital as the unit of randomization, intervention, and analysis.

Setting.— Thirty-seven community hospitals in Minnesota.

Patients.— All patients with AMI admitted to study hospitals over 10 months before (1992-1993, N=2409) or after (1995-1996, N=2938) the intervention.

Intervention.— Using a validated survey, we identified opinion leaders at 20 experimental hospitals who influenced peers through small and large group discussions, informal consultations, and revisions of protocols and clinical pathways. They focused on (1) evidence (drug efficacy), (2) comparative performance, and (3) barriers to change. Control hospitals received mailed performance feedback.

Main Outcome Measures.— Hospital-specific changes before and after the intervention in the proportion of eligible patients receiving each study drug.

Results.— Among experimental hospitals, the median change in the proportion of eligible elderly patients receiving aspirin was +0.13 (17% increase from 0.77 at baseline), compared with a change of −0.03 at control hospitals (P=.04). For β-blockers, the respective changes were +0.31 (63% increase from 0.49 at baseline) vs +0.18 (30% increase from baseline) for controls (P=.02). Lidocaine use declined by about 50% in both groups. The intervention did not increase thrombolysis in the elderly (from 0.73 at baseline), but nearly two thirds of eligible nonrecipients were older than 85 years, had severe comorbidities, or presented after at least 6 hours.

Conclusions.— Working with opinion leaders and providing performance feedback can accelerate adoption of some beneficial AMI therapies (eg, aspirin, β-blockers). Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine). However, it is more difficult to increase use of effective but riskier treatments (eg, thrombolysis) for frail elderly patients.

THE INFLUENCE OF local medical opinion leaders in the diffusion and adoption of new medical treatments has been recognized for almost half a century.1,2 Opinion leaders are not necessarily innovators or authority figures, but are trusted by their colleagues to evaluate new information and assess the value of new medical practices in the context of local group norms3; are approached frequently for clinical advice; have good listening skills4; and are perceived as clinically competent and caring.5 Many researchers and policymakers advocate recruiting opinion leaders in ongoing quality improvement efforts, in part because of the potential efficiency of capitalizing on local volunteers skilled in changing practice patterns.6 Yet, evidence supporting such interventions is limited,4,7,8 including only 1 randomized controlled trial (RCT) that enlisted local opinion leaders to reduce unnecessary cesarean deliveries in Canada.4 No well-controlled study has examined the effectiveness of recruiting opinion leaders to influence the adoption of underused, lifesaving interventions for major acute illnesses, such as acute myocardial infarction (AMI).

The selection of treatments for AMI patients represents one of the most critical decisions in medical practice.9 Coronary heart disease is the leading cause of death in the United States.10 Large RCTs and national guidelines strongly support the early administration of aspirin, β-blockers, and thrombolytic agents for AMI because they substantially reduce mortality and morbidity in eligible patients.9,11- 18 However, a meta-analysis of 14 RCTs of lidocaine prophylaxis to reduce ventricular fibrillation during AMI indicates that this practice may lead to increased mortality, especially in uncomplicated MI.19 The national guidelines also recommend avoidance of lidocaine prophylaxis.17,18 Yet, recent studies of actual practice have found substantial nonadherence to these recommendations, resulting in potentially avoidable morbidity and mortality.20,21 Our previous report of baseline data at the 37 hospitals participating in this study indicated that only 53% of eligible patients received β-blockers.21 Although aspirin use and thrombolysis were high (87% and 81%, respectively) among eligible nonelderly patients, only 76% and 69% of eligible elderly patients (aged 65 years or older) received aspirin and thrombolytic agents, respectively. About 20% of patients received prophylactic lidocaine.

In this article we report the results of a large statewide RCT that combined identification and involvement of local opinion leaders with performance feedback to improve quality of care for AMI. Specifically, we sought to increase adherence to the national (American College of Cardiology/American Heart Association [ACC/AHA]) guidelines recommending (1) increased use of highly effective drugs for eligible AMI patients, ie, β-blockers in all patients and aspirin and thrombolysis in the elderly, and (2) reduced use of an ineffective treatment, ie, prophylactic lidocaine.

Background National guidelines have encouraged increased use of thrombolytic therapy for elderly patients with acute myocardial infarction (AMI). However, evidence supporting thrombolytic therapy in patients 75 years and older is lacking. In a retrospective cohort study of 2659 elderly AMI patients, we determined the association between thrombolytic use and in-hospital mortality by age and among patients with or without absolute or relative contraindications to thrombolytic treatment.

Methods We abstracted the medical records of 2659 elderly patients admitted with AMI at 37 Minnesota community hospitals between 1992 and 1996. The main outcome measure was in-hospital mortality, controlling for demographic, clinical, comorbidity, and severity-of-illness variables.

Results Sixty-three percent of 719 eligible patients received thrombolytic therapy. Twenty-seven percent of thrombolytic recipients had absolute contraindications to treatment. Patients receiving thrombolytic agents had fewer and less severe comorbidities than those not receiving thrombolytic therapy. There was a 4% increase in the odds of death for every 1-year increase in age for all thrombolytic recipients vs nonrecipients (odds ratio [OR], 1.04 per year; 95% confidence interval [CI], 1.01-1.08; P = .03). Among patients with 1 or more contraindication, the OR for death associated with thrombolytic use was 1.57 (95% CI, 1.03-2.40; P = .04). The adjusted odds of death among eligible thrombolytic recipients (vs nonrecipients) increased significantly with age (OR, 1.08 per year; 95% CI, 1.02-1.14; P = .008). Among eligible patients aged 80 to 90 years, the predicted odds of death among thrombolytic recipients vs nonrecipients was 1.4. Among eligible patients younger than 80 years, thrombolytic use was associated with reduced mortality.

Conclusions Our findings suggest the need for more research on the effectiveness of thrombolytic therapy for AMI patients 75 years and older and for more careful selection of elderly patients for this treatment.