Underutilization of Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction in Medicaid Patients Relative to Private Insurance Patients

School of Public Health, University at Albany, Albany, New York.
Journal of Interventional Cardiology (Impact Factor: 1.18). 08/2013; 26(5). DOI: 10.1111/joic.12059
Source: PubMed


To determine whether disparities in access to invasive cardiac procedures still exist for Medicaid patients, given how old earlier studies are and given changes in the interim in appropriateness guidelines.
A total of 5,022 Medicaid and private insurance patients in New York from January 1, 2008 through December 31, 2009 under age 65 with ST-elevation myocardial infarction (STEMI) were compared with regard to their access to percutaneous coronary interventions (PCI) before and after controlling for numerous patient characteristics and other important factors.
Medicaid patients were significantly less likely to be admitted initially to a hospital certified to perform PCI (90.4% vs. 94.3%, P < 0.001). Also, Medicaid patients were found to be significantly less likely to undergo PCI than other patients (adjusted odds ratio [AOR] = 0.81, 95% CI 0.66, 0.98, P = 0.03). When the probability of each hospital performing PCI for STEMI patients was controlled for, Medicaid patients were still less likely to undergo PCI after controlling for other risk factors (AOR = 0.80, 95% CI 0.65, 0.99, P = 0.04).
Medicaid STEMI patients are significantly less likely to undergo PCI within the same day of admission as private pay patients even after adjusting for patient characteristics related to receiving PCI, and the strength of this relationship is not diminished when controlling for whether the admitting hospital has approval to perform PCI or controlling for the tendency of the admitting hospital to treat STEMI with PCI.

1 Follower
14 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of Massachusetts's healthcare reform on use of coronary revascularization procedures, in-hospital and 1-year mortality by race/ethnicity, education, and sex. Using hospital claims data, we compared differences in coronary revascularization rates [coronary artery bypass grafting or percutaneous coronary intervention] and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents age 21-64 hospitalized with a principal discharge diagnosis of ischemic heart disease pre (November 1, 2004 to July 31, 2006) and post (December 1, 2006 to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted-logistic regression assessed 24,216 discharges pre-reform and 20,721 discharges post-reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the pre-reform period. Compared to whites in the post-reform period, blacks (OR=0.73, 95%CI 0.63-0.84) and Hispanics (OR= 0.84, 95%CI 0.74-0.97) were less likely and Asians (OR=1.29, 95%CI 1.01-1.65) more likely to receive coronary revascularization. Patients living in more educated communities, males, and persons with private insurance were more likely to receive coronary revascularization pre and post-reform. Compared to pre-reform, the adjusted odds of in-hospital mortality were higher in patients living in less educated communities in the post-reform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed pre- or post-reform. Reducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated pre-existing demographic and educational disparities in access to these procedures.
    Circulation 04/2014; 129(24). DOI:10.1161/CIRCULATIONAHA.113.005231 · 14.43 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Disparities in the use of invasive coronary artery revascularisation procedures to manage acute myocardial infarction (AMI) have been found in several developed economies. Factors such as socio-economic status, income and funding source may influence the use of invasive procedures and have also been associated with ongoing care. The objectives of this study were to determine whether outcomes for patients at one and five years after AMI treated with first-ever percutaneous coronary intervention (PCI) were the same for public and privately funded patients. Methods Retrospective, population-based cohort study using linked data to identify 30-day survivors of AMI treated with PCI in the index admission between 1995 and 2008 in Western Australian hospitals. The main outcome measures were admission for another PCI, re-AMI, and all-cause and cardiac mortality at one and five years. Results At one year, private patients were at greater adjusted risk for another PCI (HR 1.62 [1.36 – 1.94]; p < 0.001) than public patients, and more likely to have an additional revascularisation procedure from 90 days to 5 years (HR 1.33 [1.11 – 1.58]; p < 0.001). They were at less risk for all-cause death within five years (HR 0.69 [0.62–0.91]; p = 0.01) with a trend to reduced risk for cardiac death and re-AMI. Conclusions Treatment as a private patient for AMI with first PCI is associated with an increased likelihood of additional coronary revascularisation procedure within 12 months and to five years, and a reduced risk for all-cause mortality to 5 years. While additional procedures were not associated with poorer outcomes, there was no clear relationship between better outcomes and additional procedures. Other lifestyle and health care factors may contribute to the significant reduction in all-cause mortality and the trends to reduced hazard for AMI and cardiac death among private patients.
    BMC Health Services Research 09/2014; 14(1):405. DOI:10.1186/1472-6963-14-405 · 1.71 Impact Factor