Increasing use of medicare services by veterans with acute myocardial infarction

OBJECTIVES. Some of the nation's 26 million veterans have two government-financed health care entitlements: Medicare and the Department of Veterans Affairs (VA). The aims of this investigation were to examine trends where Medicare-eligible VA users are initially hospitalized for acute myocardial infarction (AMI) and then to assess rates of cardiac procedure use and mortality for veterans initially admitted to each system of care. METHODS. We used VA and HCFA national databases to identify VA users (age range, greater than or equal to 65 years) who were initially admitted to a VAMC or Medicare financed hospital (Medicare hospital) with a primary diagnosis of AMI between January 1, 1992, and December 31, 1995, (n = 47,598). We examined the use of cardiac procedures (cardiac catheterization [CC] coronary artery bypass surgery [CABG], and coronary angioplasty [CA] and mortality (30-day and 1-year) by the type of initial admitting hospital within each system of care, RESULTS. Almost 70% of VA users hospitalized for AMI were initially admitted to Medicare hospitals versus VAMCs between 1992 (64%) and 1995 (72%). After adjusting for patient characteristics in logistic models, VA users initially hospitalized in Medicare hospitals were significantly more likely to undergo cardiac procedures than were VA users hospitalized in VAMCs. Differences in the odds of receiving a procedure were most significant when comparing Medicare hospitals with onsite cardiac technology to VA hospitals without on-site cardiac technology (CC: OR 4.34, 95% CI 3.98-4.73; CABG: OR 2.16, 95% CI 1.92-2.43; CA: OR 4.56, 95% CI 3.98-5.25). We found no significant differences in 30-day and 1-year adjusted mortality rates between VA users initially admitted to VAMCs or Medicare hospitals. CONCLUSIONS. Medicare-eligible VA users are increasingly hospitalized in Medicare hospitals for AMI. VA users cared for in Medicare hospitals receive more cardiac procedures but have the same survival as VA users cared for in VAMCs. These findings have policy implications for access, quality, and costs in both systems of care.