Process of care and outcome after acute myocardial infarction for patients with mental illness in the VA health care system: are there disparities?

Quality of care for acute myocardial infarction in elderly patients with alcohol-related diagnoses

BACKGROUND

Elderly adults with alcohol-related diagnoses represent a vulnerable population that may receive lower quality of treatment during hospitalization for acute myocardial infarction. We sought to determine whether elderly patients with alcohol-related diagnoses are less likely to receive standard indicators of quality care for acute myocardial infarction.

METHODS

We conducted a retrospective cohort analysis using administrative and medical record data from the Cooperative Cardiovascular Project. Subjects were Medicare beneficiaries with a confirmed principal discharge diagnosis of acute myocardial infarction from all acute care hospitals in the United States over an 8-month period. Our primary outcome was the receipt of 7 guideline-recommended care measures among all eligible patients and patients who were ideal candidates for a given measure.

RESULTS

In all, 1,284 (1%) of the 155,026 eligible patients met criteria for an alcohol-related diagnosis. Among the alcohol-related diagnoses, 1,077/1,284 (84%) were for the diagnoses of alcohol dependence or alcohol abuse. Patients with alcohol-related diagnoses were less likely than those without alcohol-related diagnoses to receive beta-blockers at the time of discharge (55% vs. 60%, p = 0.02). We found no other significant differences in performance of the quality indicators after stratifying by indication and adjustment for baseline characteristics.

CONCLUSIONS

Alcohol-related diagnoses are not a barrier to receiving most quality of care measures in elderly patients hospitalized for acute myocardial infarction.

Health care utilization and receipt of cholesterol testing by veterans with and those without mental illness

OBJECTIVE

We examined the relationship between mental illness, health care utilization and rates of cholesterol testing.

METHODS

We conducted a retrospective cohort study using Veterans Affairs (VA) administrative data on 64,490 United States veterans who used VA New England Health Care System outpatient services between January 1998 and June 2001. A total of 10,100 veterans (15.7%) had a mental illness treated with medication. We examined the interaction between mental illness and outpatient service utilization with respect to the likelihood of receiving a cholesterol test, adjusting for major demographic and clinical covariates.

RESULTS

Among veterans using VA outpatient services infrequently, those with mental illness were less likely than non-mentally ill control subjects to receive a cholesterol test during the study period (first quartile adjusted OR=0.45, 95% CI=0.37-0.54; second quartile adjusted OR=0.50, 95% CI=0.45-0.57). Mentally ill subjects with more frequent utilization of VA services were as likely as (third quartile adjusted OR=1.01, 95% CI=0.91-1.13) or more likely than (fourth quartile adjusted OR=2.73, 95% CI=2.46-3.03) non-mentally ill subjects to receive cholesterol testing.

CONCLUSIONS

Mental illness was associated with a lower likelihood of cholesterol testing in subjects who used fewer VA outpatient services. The observed disparity attenuated at higher levels of service utilization.

Physicians' perceptions of patients' social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease

OBJECTIVES

A growing body of evidence suggests that provider decisionmaking contributes to racial/ethnic disparities in care. We examined the factors mediating the relationship between patient race/ethnicity and provider recommendations for coronary artery bypass graft surgery.

METHODS

Analyses were conducted with a data set that included medical record, angiogram, and provider survey data on postangiogram encounters with patients who were categorized as appropriate candidates for coronary artery bypass graft surgery.

RESULTS

Race significantly influenced physician recommendations among male, but not female, patients. Physicians' perceptions of patients' education and physical activity preferences were significant predictors of their recommendations, independent of clinical factors, appropriateness, payer, and physician characteristics. Furthermore, these variables mediated the effects of patient race on provider recommendations.

CONCLUSIONS

Our findings point to the importance of research and intervention strategies addressing the ways in which providers' beliefs about patients mediate disparities in treatment. In addition, they highlight the need for discourse and consensus development on the role of social factors in clinical decisionmaking.

Mental disorders and revascularization procedures in a commercially insured sample

OBJECTIVE

The objective of this study was to determine if receipt of revascularization was similar among commercially insured adults with mental disorders compared with people without mental disorders.

METHODS

This was a retrospective analysis of a 100% sample of Blue Cross/Blue Shield of Iowa administrative claims data, 1996 to 2001. Logistic regression was used to calculate unadjusted and adjusted odds ratios (OR) for receipt of angioplasty (PTCA) and bypass graft surgery (CABG) within 30 days of discharge.

RESULTS

A total of 3368 adults, aged 18 to 64 years, were hospitalized for myocardial infarction (MI) and 40% (n = 1342) had a mental disorder. Subjects with mental disorders were more likely to be younger, female, urban residents, and to have increased cardiovascular and medical comorbidity. They were similarly likely as subjects without mental disorders to have received PTCA (OR, 1.10; 95% confidence interval [CI], 0.95-1.29) and CABG (OR, 0.89; 95% CI, 0.71-1.11) in analyses adjusted for demographic and clinical characteristics. Revascularization rates did not differ by mental disorder type, with few exceptions.

CONCLUSIONS

Receipt of revascularization was similar for patients with and without mental disorders. Our results may differ from previous findings as a result of the younger population studied and increased comorbidity in people with mental disorders, which may have resulted in a contraindication for surgical intervention. Conversely, the increased burden of comorbidity could suggest that these patients should have received PTCA at higher rates because of the better prognosis associated with revascularization as compared with medical management. Prospective analyses with review of clinical data and behavioral risk factors are necessary to determine why some patients with mental illness may be less likely to receive cardiac interventions.

Is lipid-lowering therapy underused by African Americans at high risk of coronary heart disease within the VA health care system?

OBJECTIVES

We examined whether racial differences exist in cholesterol monitoring, use of lipid-lowering agents, and achievement of guideline-recommended low-density lipoprotein (LDL) levels for secondary prevention of coronary heart disease.

METHODS

We reviewed charts for 1045 African American and White patients with coronary heart disease at 5 Veterans Affairs (VA) hospitals.

RESULTS

Lipid levels were obtained in 67.0% of patients. Whites and African Americans had similar screening rates and mean lipid levels. Among the 544 ideal candidates for therapy, rates of treatment and achievement of target LDL levels were similar.

CONCLUSIONS

We found no disparities in cholesterol management. This absence of disparities may be the result of VA quality improvement initiatives or prescription coverage through the VA health care system.