Beta-Blocker, Lipid Treatment Increases With Cardiology Visits, GAO Finds

Managed care organizations have a "unique opportunity" to increase use of beta-blockers and cholesterol-lowering drugs in post-heart attack patients, the General Accounting Office states in a recently released study of drug usage patterns by doctors providing regular follow-up treatment.

In a study of treatment patterns for 284 Medicare patients in HMO programs, GAO found that beta-blockers and cholesterol-lowering drugs were used about 50% more often by patients who had regular cardiology visits compared to those visiting non-specialists or infrequently visiting a specialist.

The study found that 45% of patients with regular cardiology visits took a cholesterol-lowering drug compared to 30% of those who did not have regular visits.

For beta-blockers, 50% of patients with regular visits to a cardiologist took the drugs compared to 34% of those who did not. Overall, 36% of enrollees took cholesterol-lowering drugs and 40% took beta-blockers.

The study also looked at the difference in post-infarction use of aspirin among patients treated by specialists and non-specialists. There was no significant difference in use of aspirin between the two groups.

On the whole, GAO said, "our conclusion that patients under regular care of a cardiologist are more likely to take recommended medications parallels the findings of other studies of physician specialty differences" in the U.S.

The potential for expanding the use of treatment patterns mirroring those of specialists is an opportunity for HMOs "because HMOs, unlike fee-for-service insurers, can actively manage care," GAO notes.

"Thus, HMOs can educate physicians they employ about treatment guidelines, review clinical records to ensure that patients are taking appropriate medications, or take other organizational actions to improve the quality of care provided by all types of physicians that are not possible in fee-for-service settings."

GAO conducted the study in spring 1997 by surveying individuals enrolled in Medicare HMOs when hospitalized for acute myocardial infarction between May and July 1995. All patients were part of the Health Care Financing Administration's Cooperative Cardiovascular Project.

Ten Democrat and Republican legislators, including Senate Health, Education, Labor & Pensions Committee Chairman Jeffords (R-Vt.) and House Ways & Means/Health Subcommittee ranking Democrat Stark (Calif.) requested the study.

The most "direct" explanation for the study's finding is that "cardiologists treat heart attack survivors differently than physicians who are not heart specialists," GAO concluded.

GAO also looked at the hypothesis that "patients who are most steadfast in their pharmaceutical regimens may also be the most likely to seek specialty care." That hypothesis was not supported by a multivariate analysis because "the variables associated with having regular cardiology appointments and with taking heart drugs" were different.

A separate analysis found the patients most likely to receive regular care by a cardiologist were white (43% had regular appointments v. 22% of non-whites); relatively young (47% of those 73 years old or younger had regular appointments v. 34% of those 74-86); and had "relatively severe" heart attacks.

GAO acknowledged that HCFA, after reviewing a draft version of the report, was concerned that the study's methodology "had the potential to introduce selection biases" because Medicare HMO enrollees who develop chronic conditions frequently switch out of managed care and into the standard Medicare program.

However, GAO defended its approach, noting that "the potential of any such selection bias was minimal because few patients in our initial sample - less than 4% - were dropped from the study" because they had returned to fee-for-service Medicare between their heart attack hospitalizations and the survey.

Another concern among HCFA reviewers was that specialists provide drugs to patients who will not be helped by them, but GAO defended its approach saying that the drugs they selected as indicators of care "have been demonstrated to have great clinical benefits and few absolute contraindications."