highlight complexity of treating heart disease

Medical advances seem to be shifting the care of patients with coronary artery disease away from hospitals to outpatient care for more routine procedures. What happens after they go home has a lot to do with how financially secure they are.

Two studies just published in medical journals underscore the complexity of dealing with a disease responsible for one in five deaths in this country each year.

According to the American Heart Association, 1.2 million Americans suffer a first or repeat heart attack every year, and more than 15.8 million are living with the aftermath of coronary artery disease.

Researchers in Michigan used discharge data on 6 million patients a year from 458 hospitals throughout the United States. They found that the hospitalization rate for heart-attack care declined by nearly 11 percent between 2002 and 2005, despite the aging population.

Hospital admissions for heart attacks fell from 661,000 in 2002 to 591,000 in 2005, while hospitalizations to restore blood flow to a blocked coronary artery remained fairly steady at between 794,000 and 815,000 a year, according to the report in the American Journal of Cardiology.

One reason for these trends is that fewer Americans are smoking, particularly in middle and older age. Also, more people with coronary artery disease are being treated with aspirin and statin drugs rather than medical or surgical procedures. Because of these developments, fewer patients are arriving at hospitals with heart attacks that might require more aggressive treatment.

The biggest change seems to be that fewer coronary artery bypasses are being done, and more procedures using angioplasty and arterial stents are being done_ many in catheterization labs that are either affiliated with hospitals or free-standing _ with patients going home the same day.

So even if coronary artery disease is still on the rise, "it may not necessarily translate into more hospital utilization because of recent procedural and medical advances," said Dr. Brahmajee Nallamothu, lead author of the study, which also involved researchers from the health consulting firm Solucient.

Another study, published in The Journal of the American Medical Association, found that many heart-attack patients, even those with health insurance, say a lack of money keeps them from getting recommended follow-up care or medicines.

That study followed 2,498 patients at 19 medical centers around the country for 12 months after admission.

Led by Dr. Harlan Krumholz, a professor of public health at the Yale School of Medicine, the researchers found that one out of five patients said financial constraints kept him from seeking health-care services during the follow-up period, and one in eight said a lack of money kept him from filling prescriptions for a vital medicine.

Those with financial barriers to health care had higher rates of angina, a worse quality of life and poorer overall physical and mental function _ both at the time of their heart attack and a year later _ the researchers found. Those who didn't take medicines prescribed to them had especially worse medical outcomes.

"They had poorer health-status outcomes overall and had a 50 percent higher chance of being re-hospitalized for any reason and a 70 percent higher chance of being re-hospitalized for a cardiac condition," said Dr. Ali Rahimi, a Yale researcher who was first author of the study.

Yet Krumholz noted that 68 percent of those who said they had financial barriers to care had health insurance, and 47 percent had Medicaid or Medicare coverage. The study period ended in mid-2005, before the new Medicare benefit for drug coverage became available.

Krumholz said that even to the extent the new coverage might help, "our study may be highlighting under-insurance, which can mean that too few services are covered or the coverage is inadequate. There is a need to develop approaches that will mitigate this increased risk and address this barrier to care and medications so that patients aren't avoiding care or cutting pills in half."

source:www.scrippsnews.com