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No Pain, But No Gain? The Disappearance of Angina Hospitalizations, 1992–1999

Saver, Barry G. MD, MPH*; Dobie, Sharon A. MCP, MD; Green, Pamela K. MPH, PhD; Wang, Ching-Yun PhD; Baldwin, Laura-Mae MD, MPH

doi: 10.1097/MLR.0b013e31819e1f53
Brief Report

Background: Hospitalization for angina is commonly considered an ambulatory care sensitive hospitalization and used as a measure of access to primary care.

Objective: To analyze time trends in angina-related hospitalizations and seek possible explanations for an observed, marked decline during 1992 to 1999.

Research Design: We analyzed Medicare claims of SEER-Medicare control subjects for occurrence of angina hospital discharges, using the Agency for Healthcare Research and Quality Prevention Quality Indicator (PQI) definition, along with occurrence of related events including angina admissions with revascularization, angina admissions discharged as coronary artery disease (CAD) or myocardial infarction, and overall ischemic heart disease discharges.

Subjects: Approximately 124,000 cancer-free Medicare beneficiary/ies, with subjects contributing data for 1 to 8 years.

Results: Angina PQI hospital discharges declined 75% between 1992 and 1999. CAD hospital discharges rose in a reciprocal pattern, while angina discharges with revascularization declined and discharges for myocardial infarction and ischemic heart disease were relatively constant during this time period.

Conclusions: The marked decline in angina PQI hospital discharges during 1992–1999 does not appear to represent improvements in access to care or prevention of heart disease, but rather increased coding of more specific discharge diagnoses for CAD. Our findings suggest that angina hospitalization is not a valid measure for monitoring access to care and, more generally, demonstrate the need for careful, periodic re-evaluation of quality measures.

From the *Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts; †Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington; and ‡Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.

Supported by National Cancer Institute (grant 1 R01 CA104935) and the collection of the California cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the National Cancer Institute's Surveillance, Epidemiology, and End Results Program under contract N01-PC-35136 awarded to the Northern California Cancer Center, contract N01-PC-35139 awarded to the University of Southern California, and contract N02-PC-15105 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention's National Program of Cancer Registries, under agreement U55/CCR921930-02 awarded to the Public Health Institute.

Presented at the 2008 meeting of the North American Primary Care Research Group, Rio Grande, Puerto Rico, November 17, 2008.

The ideas and opinions expressed herein are those of the author(s) and endorsement by the State of California, Department of Public Health the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors is not intended nor should be inferred.

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors.

Reprints: Barry G. Saver, MD, MPH, Department of Family Medicine and Community Health, University of Massachusetts, Benedict Building A3-146, 55 Lake Avenue North, Worcester, MA 01655-0002. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.