HMO Members Have Poor Heart Attack Survival Rate

The review of nearly 4,000 hospitalized heart attack patients under 65, presented November 12 at the American Heart Association's 70th Scientific Sessions, found that after taking into consideration the type of hospital and whether the patient was treated by a cardiologist or primary care physician, the increased risk for death for HMO members was 216 percent higher.

"This is roughly twice the rate of deaths than fee-for-service patients," reports Paul Casale, M.D., of the Lancaster Heart Foundation.

One quarter of the participants in the study belonged to HMOs near Philadelphia. "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."

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."