Intensity of antianginal therapy in patients referred for coronary angiography: A comparison of fee-for-service and health maintenance organization therapeutic strategies

Background: No formal criteria have been developed to guide medical therapy for angina prior to revascularization, and no comparisons have been made b etween health maintenance organization (HMO) and fee-for-service (FFS) hosp itals with respect to angina treatment. Hypothesis: Using a literature-based measure of medical intensity, we teste d the hypothesis that there is no difference in anginal medical therapeutic intensity between HMO and FFS systems. Methods: For each,antianginal drug, we developed a model from which an inte nsity score between 0 and 100 could be calculated. Average and maximal dail y doses of drug were fit to a sigmoid curve such that they represented scor es of 50 and 99 respectively. Overall intensity scores were obtained by wei ghted and unweighted averaging of three scores from nitrates, calcium-chann el blockers, and beta blockers. This model was applied to 199 patients unde rgoing angiography at an FFS and an HMO hospital. Results: HMO patients wen taking more classes of antianginal drug (1.9 vs. 1.0, p < 0.001). Overall unweighted (17.7 vs. 11.7, p = 0.02) and weighted (27.3 vs. 16.9, p = 0.003) intensity scores for both HMO and FFS patients w ere low. HMO intensity scores for the use of beta blockers were greater tha n FFS scores (19.2 vs. 9.6, p = 0.002). The intensity scores for the use of nitrates and calcium blockers were similar. Conclusions: Models for the measurement of anginal medical therapy intensit y can provide important information regarding medical therapy prior to reva scularization. The overall intensity of medical therapy was low in both hea lth care systems. These findings have important implications for patient ma nagement, guideline development, and national healthcare policy.