CONCLUSION: There is significant discrepancy between qualitative and quantitative strategies to diagnose CHF, which may explain non-compliance with AHRQ recommendations. Physicians who use either standard alone, risk undertreating or overtreating patients which may lead to morbidity. We conclude that CHF guidelines must develop a clinically acceptable way of identifying patients with CHF in order to insure that appropriate care is delivered and that patient outcomes are maximized. PURPOSE: Studies examining some of the clinical and non-clinical determinants of outcomes of acute myocardial in the VA suggest that age; race, co-morbid illnesses. and availability of cardiac surgical services all play a role. However, few data are available on the regional variation in health care utilization and outcomes during and after acute myocardial infarction. The purpose of our study was to examine regional variation in utilization and outcomes during the acute and chronic care of patients with acute myocardial infarction (AMI). Examining these differences will lead to a better understanding of potentially modifiable variables and processes of care that influence patient outcomes METHODS: Using national VA databases, we identified all veterans who were hospitalized for AMI at any VA Medical center between 10/90 to 10/97. Demographic, inpatient, outpatient, mortality and readmission data were extracted from the VA's administrative databases for the four regions: Northeast, South, Midwest and West. Multivariable Cox proportional hazards models, controlled for comorbidity, were used to assess the effect of independent variables on time to death and readmission. RESULTS: We identified 67,889 patients with AMI who were 98% male at mean age of65 years. There were no significant regional differences in patients' demographic data. Patients in the Northeast had a greater prevalence of comorbid conditions and longer lengths of stay during the index AMI hospitalization (14 days in the NE Vs 10 days in the W). There was no variation in the rates of cardiac procedures (PTCA and/or CABG) among the regions during the index admission. Region of the country was an independent predictor of mortality. Subsequent adjusted all-cause mortality after discharge from the index hospitalization was lower in the Northeast (OR = .910 CI .86 ± .95) and the West (OR = 0.871 CI .87 ± . 95). Patients in the Northeast and West had greater cardiology or primary care follow up at 60 days and 1 year post discharge than patients in the South. Outpatient follow up appeared to account for a substantial amount of the regional variation in all-cause mortality.