Wednesday, February 22, 2012

Widening Geographic Disparities in Hospitalized Heart Attack Incidence and Outcome Rates

featuring Q&A with Robert W. Yeh, MD, MBA, interventional cardiologist at the Mass General Heart Center



In this third discussion about heart health, Robert W. Yeh, MD, MBA, an interventional cardiologist at the Mass General Heart Center, talks about geographical disparities in the incidence and outcomes of hospitalized myocardial infarction, more commonly known as heart attack, in the Medicare population.  Yeh was the lead author of a recent study in American Heart Association’s Circulation: Cardiovascular Quality and Outcomes.


What are some ways people can be more heart healthy?  Is it ever too late to change lifestyle habits (i.e. diet and exercise) to reduce the chances of having a major health event like a heart attack?

Living a healthy lifestyle is the most important thing that people can do.  That means, first and foremost, not smoking, staying physically active and eating in moderation.  On top of that, regular visits to your physician to make sure your blood pressure and cholesterol are well controlled are really important in preventing the development of cardiovascular disease.  It’s never too late to start.  Even patients who have sustained major heart attacks can greatly improve their long-term risk by simply improving their lifestyle and adhering to prescribed medications. 

Annually, how many people in the U.S. experience heart attacks?  What are the symptoms of a heart attack, and what should someone do if he/she has those symptoms?

The American Heart Association estimates that nearly a million people in the U.S experience heart attacks each year (~600,000 new heart attacks and ~325,000 recurrent heart attacks).  Typical symptoms include the development of pain or pressure in the center of the chest, sometimes moving toward to the jaw or arm, and often in association with shortness of breath, nausea, and/or sweating.  However, It’s important to note that symptoms of heart attacks can be very atypical, particularly in women, with some patients developing nausea and vomiting without chest pressure, for example.  If one develops these types of symptoms that don’t resolve after a few minutes, call 911 immediately.  In the case of heart attacks, rapid diagnosis and treatment, which usually entails opening a blocked blood vessel in a heart artery with angioplasty, is critical.

In your data collection, what procedures were you looking at and what was the timeframe?  

The primary goal of our research was to compare the rates of heart attacks as well as the mortality associated with heart attacks across different geographic regions in the US between 2000 and 2008.  We also compared rates of cardiovascular procedures such as cardiac catheterization (to diagnose blockages in heart arteries), angioplasty and bypass surgery in patients who sustained heart attacks.

What were the major goals behind this research?

We had previously demonstrated that there had been a dramatic decline in heart attacks in Northern California over the past decade in a study published in the New England Journal of Medicine.  However, when we published that study, we and many others wondered whether these observations were relevant to other parts of the US, where rates of cardiovascular risk factors may be much higher.  Our goal in this study was to examine these trends in a national sample of Medicare patients, and compare recent trends in heart attacks and their outcomes among states and US Census Divisions.

What were the major findings in this study?  Were there any results that surprised you?

There was good news and bad news.  The good news was that significant declines in heart attack incidence as well as short-term mortality had indeed declined in every US Census Division between 2000 and 2008.  However, the bad news was that the known disparities across geographic regions in heart attack incidence as well as in procedures such as angioplasty had actually widened over time.  These results were quite surprising – there’s plenty of news coverage about widening economic disparities – the “rich getting richer,” but this is one of the first studies suggesting that the healthy are getting healthier, and the gap in cardiovascular disease prevention between regions may be widening.

Research in this study shows that patients in the Mountain Division had the lowest rates of congestive heart disease, prior heart attack, stroke, cerebrovascular disease and peripheral vascular disease among the regions.  Is there any explanation for this?

I think the most likely explanation is that people living in these areas smoke less and live more active lifestyles.  The Mountain and Pacific Divisions were really the healthy outliers in this study, and when we think about people’s lifestyles in states like Utah, Colorado and California, there is probably a strong cultural effect that promotes healthy living in these states, perhaps, relative to others.  It’s really a hypothesis, though, since proving that type of causality is really challenging, and not something that we could do in this study.

Do you have any insight on why the rates of procedures were much higher in the Mountain Division and the lowest in New England and the Mid Atlantic divisions?  Does the issue of reimbursement come into play at all?

This is a million dollar question – how do we explain geographic variation in medical care utilization, procedure rates, and ultimately costs of care.  A lot of very good research has been and continues to examine this exact issue, and at some level, I think it has been well established that the method of reimbursement clearly is one driver of differences in the intensity of care.  But in this case, all of our study patients were insured under fee-for-service Medicare plans, so it is likely that there are additional forces at play.  There are likely to be regional “medical cultures” influencing both patients and providers that may support more or less invasive management of coronary disease.  It’s an area of intense investigation particularly in the current healthcare climate.

What should physicians and hospitals take away from this research?

I think one of the very impressive findings we saw was the dramatic reduction in heart attack mortality over time.  Coupled with other recent evidence, it’s pretty clear that hospitals and physicians are winning the battle in treating heart attacks in patients who make it to the hospital.  We’re also doing better in preventing heart attacks, but clearly more can be done here.  In many ways, prevention is so much more challenging than treatment, since there are so many more factors involved and patients at risk.  One of the important policy takeaways that I see is that if health equity is a goal (and I think that it is), devoting more resources to the primary care and public health setting in those areas that continue to have higher rates of cardiovascular disease is necessary.

What are your expectations for the future?  Will heart attack incidence rates continue to decline?  If yes, will geographic disparities continue to widen?

I do think heart attack incidence will continue to decline, particularly in the high incidence areas where we have yet to reach an inflection point.  It’s both my expectation and my hope that disparities will narrow in the next decade – we already have seen that disparities in heart attack mortality have narrowed.  But because incidence is so strongly tied to prevention and health care access, how these trends continue over the next decade will be closely tied to the success of health care reform in delivering effective primary care and public health to less healthy areas.


For more information about heart health, visit the MGH Heart Center’s page.


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