Posted on Mar 31, 2019, 10 p.m.
According to a cohort study of over 4 million Medicare recipients, twenty years of better survival in acute myocardial infarction was accompanied by changing demographics and greater use of certain evidence based therapies, as published in JAMA Network Open.
There was a 38% relative decline in hospitalizations for acute MI from 1995 to 2014 according to Harlan Krumholz, MD, SM, representing a drop from 914 to 566 per 100,000 person years. There was also observed improvements for patients who were admitted for 30 day all cause mortality decreasing from 20% to 12.4%; 30 day all cause readmissions dropping from 21% to 15.3%; and 1 year recurrent acute MI changing from 7.1% to 5.1%; such improvements held consistent across age, sex, race, and eligibility for Medicaid.
Majority of hospitals and counties showed improvements, but health priority areas and areas with persistently high mortality rates had slower than average declines in acute MI morality, and may benefit from future improvement activities.
Medicare inpatient payments per acute MI discharge increased from $9,282 to $11,031, though total cost declined due to the number of hospitalizations reducing. Median hospital stay decreased from 6 days to 3 days; increased rates of 30 days inpatient catheterization went from 44.2% to 59.9%; inpatient percutaneous coronary intervention increased from 18.8% to 43.3%; and coronary artery bypass graft surgery dropping to 10.2% from 14.4%.
Average acute MI patient ages became older increasing from 76.9 years in 1995 to 78.2 years in 2014, which is suggestive of delaying the onset of acute MI, according to the researchers. Hospitalized patients were 49.5% less likely to be female and 91% less likely to be white; and despite increases in general comorbidities over the study period proportions of patients with cerebrovascular disease, stroke, unstable angina, and valvular heart disease declined.
This study was based on Medicare free for service patients aged 65+, as such limited results have questionable applicability to the Medicare Advantage population and younger patients. The study was restricted to 1995 to 2014 to keep billing codes consistent, however lack of granular data such as troponin and door to balloon time for adjustments also limit the study.
“...Some of these improvements have been reported in previous studies but were not as comprehensive of over a twenty year time frame across the entire nation; as such results reveal insights about what has been achieved in reducing and mitigating acute MI among Medicare beneficiaries...” The researchers concluded “...Use of evidence based strategies has improved over the years, speed of reperfusion therapy for ST-segment elevation acute MI also improved, as did use of PCI in general...”
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