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CLINICAL STUDIES

Influence of insurance type on the use of procedures, medications and hospital outcome in patients with unstable angina: results from the GUARANTEE registry

Nathan R. Every, MD, MPH^a, Christopher P. Cannon, MD, FACC^*, Christopher Granger, MD, FACC, David J. Moliterno, MD, FACC, Frank V. Aguirre, MD, FACC, J. David Talley, MD, FACC^||, Joan Booth, RN, Shelly Sapp, MS, James J. Ferguson, MD, FACC^¶ for the GUARANTEE investigators

^a Northwest Health Services Research and Development Program, Puget Sound Veteran’s Administration Healthcare System, Seattle, Washington, USA
^* Harvard Medical School, and Brigham and Women’s Hospital, Boston, Massachusetts, USA
Duke University Medical Center, Durham, North Carolina, USA
Cleveland Clinic Foundation, Cleveland, Ohio, USA
St. Louis University Hospital, St. Louis, Missouri, USA
^|| University of Arkansas, Little Rock, Arkansas, USA
^¶ Texas Heart Institute, Houston, Texas, USA

Manuscript received August 25, 1997; revised manuscript received March 30, 1998, accepted April 17, 1998.

Address for correspondence: Dr. Nathan R. Every, MITI Coordinating Center, 1910 Fairview Ave E Ste 205, Seattle, Washington 98102-3620
nevery{at}u.washington.edu

Objectives. The purpose of this study was to investigate whether or not there is an association between managed care insurance and the delivery and outcome of care in patients presenting with unstable angina.

Background. The proportion of U.S. patients with managed care health insurance is increasing. This may be associated with recent improvements in the control of health care costs. It is unknown whether or not there is a difference in process of care in angina patients presenting with managed care versus fee-for-service health insurance.

Methods. We compared baseline characteristics, process and outcome of care in 636 patients with managed care insurance (MC) and 1,404 patients with fee-for-service (FFS) insurance who presented with unstable angina to 35 hospitals participating in the global Unstable Angina Registry and Treatment Evaluation (GUARANTEE) Registry.

Results. Although, there was little difference in baseline characteristics and hospital treatments between cohorts, MC patients were more likely to be discharged on guideline-recommended medications (aspirin and beta-adrenergic blocking agents). In addition, FFS patients were more likely to undergo cardiac catheterization (odds ratio = 1.25 95% confidence interval = 1.1 to 1.5), but not revascularization during the hospitalization. There was no difference in hospital mortality (0.9% versus 1.2% in MC versus FFS; p = 0.60).

Conclusions. In patients admitted with suspected unstable angina, MC patients are less likely to undergo coronary angiography, but are more likely to be discharged on indicated medications.

Abbreviations and Acronyms   AHCPR = agency for health care policy and research   AMI = acute myocardial infarction   ECG = electrocardiogram   FFS = fee-for-service   GUARANTEE = global unstable angina registry and treatment evaluation registry   MITI = myocardial infarction triage and intervention   MC = managed care insurance   U.S. = United States

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