Academic journal article Inquiry

Use of Statins by Medicare Beneficiaries Post Myocardial Infarction: Poor Physician Quality or Patient-Centered Care?

Academic journal article Inquiry

Use of Statins by Medicare Beneficiaries Post Myocardial Infarction: Poor Physician Quality or Patient-Centered Care?

Article excerpt

Abstract

Even though guidelines strongly recommend that patients receive a statin for secondary prevention after an acute myocardial infarction (MI), many elderly patients do not fill a statin prescription within 30 days of discharge. This paper assesses whether patterns of statin use by Medicare beneficiaries post-discharge may be due to a mix of high-quality and low-quality physicians. Our data come from the Centers for Medicare & Medicaid Services (CMS) Chronic Condition Data Warehouse (CCW) and include 100% of Medicare beneficiaries hospitalized for an acute myocardial infarction in 2008 or 2009. Our study sample included physicians treating at least 10 Medicare fee-for-service beneficiaries during their MI institutional stay. Physicianspecific statin fill rates (the proportion of each physician's patients with a statin within 30 days post-discharge) were calculated to assess physician quality. We hypothesized that if the observed statin rates reflected a mix of high-quality and low-quality physicians, then physician-specific statin fill rates should follow a u-shaped or bimodal distribution. In our sample, 62% of patients filled a statin prescription within 30 days of discharge. We found that the distribution of statin fill rates across physicians was normal, with no clear distinctions in physician quality. Physicians, especially cardiologists, with relatively younger and healthier patient populations had higher rates of statin use. Our results suggest that physicians were engaging in patient-centered care, tailoring treatments to patient characteristics.

Keywords

statins, prevention, cardiovascular disease, acute myocardial infarction, Medicare, physician quality

There is growing concern in the medical community regarding quality measures and guidelines that do not account for the art of prescribing and the complexity of the patient. (1,2) Pressure exists from payers and regulating agencies for physicians to conform to guidelines, and some have argued that one way to reduce costs is to require adherence to clinical guidelines. (3) However, restricting flexibility in the treatment decision may in the end jeopardize patient-centered care. (4) Cooper and Strauss discuss their concern for the potential tyranny of guidelines in a recent paper, stating that "guidelines are expressions of the optimal pathway for the average patient, but, of course, most patients are not average (pp.233)." (5) Finding the correct balance between following guidelines and patient-centered care is relatively uncharted territory and open to scientific inquiry.

We were struck with this very tension in our own study of treatments prescribed to a population of elderly patients who experienced an acute myocardial infarction (MI). Current guidelines recommend that patients with an acute MI receive a statin for secondary prevention. (6,7) The evidence for statin use is so strong that some have labeled it "effective care," such that all patients should be receiving it unless significant contraindications exist, such as hypersensitivity, unexplained persistent elevations of serum transaminases, or pregnant or nursing mothers. (8,9) As these conditions affect a small percentage of the population, treatment rates substantially less than 100% could be thought by some as underuse or ineffective care delivery. Indeed, prescribing a statin post-acute MI is now a Joint Commission core measure and a Centers for Medicare & Medicaid Services (CMS) inpatient quality reporting measure.

However, studies have reported statin rates far less than 100%. According to the Dartmouth Atlas 2013 Medicare prescription drug use, 76.9% of survivors filled a statin prescription within 6 months of post-MI discharge. (9) We found that only 62% of our study cohort (Medicare beneficiaries hospitalized in 2008-2009 for an acute MI) had a statin available within 30 days of discharge, either through a new statin prescription or through pills remaining from a prescription prior to their MI. …

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