Insurance coverage and care of patients with non-ST-segment elevation acute coronary syndromes.
ABSTRACT The impact of insurance coverage on the care of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear.
To compare NSTE ACS care patterns by insurance type.
Comparison of Medicaid patients younger than 65 years of age and Medicare patients 65 years of age or older with patients of similar age who have health maintenance organization (HMO) or private insurance coverage.
521 U.S. hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC [American College of Cardiology]/AHA [American Heart Association] Guidelines) quality improvement initiative from January 2001 through March 2005.
37,345 NSTE ACS patients younger than 65 years of age and 59,550 patients 65 years of age or older.
Guideline-recommended treatments, and in-hospital outcomes.
Medicaid was the primary payer for 18.7% (6999 of 37,345) of patients younger than age 65 years, whereas Medicare was the primary payer for 67.5% (40,199 of 59,550) of patients age 65 years or older. Medicaid patients were statistically significantly less likely to receive short-term (less than 24 hours) medications and to undergo invasive cardiac procedures than patients covered by HMO and private insurance. They also had higher mortality rates (2.9% vs. 1.2%; adjusted odds ratio, 1.33; 95% CI, 1.08 to 1.63). Medications and invasive procedures were used to a similar extent in patients with Medicare and HMO or private insurance, and respective mortality rates were not significantly different (6.2% vs. 5.6%; adjusted odds ratio, 1.08; 95% CI, 0.99 to 1.18).
Self-pay patients and patients without insurance were not assessed.
NSTE ACS patients with Medicaid (but not Medicare) as the primary payer were less likely to receive evidence-based therapies and had worse outcomes than patients with HMO or private insurance as the primary payer. The causes of these treatment differences and solutions for narrowing the gaps in quality require further investigation.
- SourceAvailable from: Christopher B Granger[Show abstract] [Hide abstract]
ABSTRACT: The purpose of this study was to examine the association between lower socioeconomic status (SES), as ascertained by years of education, and outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI). Previous studies have shown an inverse relationship between SES and coronary heart disease and mortality. Whether a similar association between SES and mortality exists in STEMI patients is unknown. We evaluated 11,326 patients with STEMI in the GUSTO-III (Global Use of Strategies to Open Occluded Coronary Arteries) trial study from countries that enrolled >500 patients. We evaluated clinical outcomes (adjusted using multivariate regression analysis) according to the number of years of education completed. One-year mortality was inversely related to years of education and was 5-fold higher in patients with <8 years compared with those with >16 years of education (17.5% vs. 3.5%, p < 0.0001). The strength of the relationship between education and mortality varied among different countries. Nonetheless, years of education remained an independent correlate of mortality at day 7 (hazard ratio per year of increase in education: 0.86; 95% confidence interval: 0.83 to 0.88) and also between day 8 and 1 year (hazard ratio per year of increase in education: 0.96; 95% confidence interval: 0.94 to 0.98), even after adjustment for baseline characteristics and country of enrollment. When the number of years of education was used as a measure of SES, there was an inverse relationship such that significantly higher short-term and 1-year mortality existed beyond that accounted for by baseline clinical variables and country of enrollment. Future studies should account for and investigate the mechanisms underlying this link between SES and cardiovascular disease outcomes.Journal of the American College of Cardiology 01/2011; 57(2):138-46. DOI:10.1016/j.jacc.2010.09.021 · 15.34 Impact Factor
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ABSTRACT: We investigated whether health insurance type (private vs Medicaid) influences the delivery of acute mental health care to patients with deliberate self-harm. Using National Medicaid Analytic Extract Files (2006) and MarketScan Research Databases (2005-2007), we analyzed claims focusing on emergency episodes of deliberate self-harm of Medicaid- (n=8,228) and privately (n=2,352) insured adults. We analyzed emergency department mental health assessments and outpatient mental health visits in the 30 days following the emergency visit for discharged patients. Medicaid-insured patients were more likely to be discharged (62.7%), and among discharged patients they were less likely to receive a mental health assessment in the emergency department (47.8%) and more likely to receive follow-up outpatient mental health care (52.9%) than were privately insured patients (46.9%, 57.3%, and 41.2%, respectively). Acute emergency management of deliberate self-harm is less intensive for Medicaid- than for privately insured patients, although discharged Medicaid-insured patients are more likely to receive follow-up care. Programmatic reforms are needed to improve access to emergency mental health services, especially in hospitals that serve substantial numbers of Medicaid-insured patients.American Journal of Public Health 04/2012; 102(6):1145-53. DOI:10.2105/AJPH.2011.300598 · 4.23 Impact Factor
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ABSTRACT: Aim: The study aimed to evaluate the relationship between insurance status and the management and outcome of acute diverticulitis in a nationally representative sample. Method: A retrospective cohort analysis of a nationally representative sample of 1,031,665 hospital discharges of patients admitted for acute diverticulitis in the 2006-2009 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project dataset. The main outcome measures included state at presentation (complicated/ uncomplicated), management (medical /surgical), time to surgical intervention, type of operation and in-patient death. Results: 207,838 discharges were identified (including 37.0% private insurance, 49.3% Medicare, 5.6% Medicaid, and 5.8% uninsured) representing 1,031,665 total discharges nationally. Medicare patients were more likely to present with complicated diverticulitis compared to private insurance patients (23.8% vs. 15.1%). Time to surgical intervention differed by insurance status. After adjusting for patient, hospital, and treatment factors, Medicare patients were less likely than those with private insurance to undergo a procedure (Medicare OR=0.86, 95% CI 0.82-0.91); while the uninsured were more likely to undergo drainage (OR=1.30, 95% CI 1.16-1.46) or a colostomy ONLY(OR=1.70, 95% CI 1.24-2.33). All patients without private insurance were more likely to die in-hospital (Medicaid OR=1.29, 95% CI 1.09-1.52, Medicaid OR=1.55, 95% CI 1.22-1.97, uninsured OR=1.41, 95% CI 1.07-1.87). Conclusion: In a nationally representative sample of patients with acute diverticulitis, patient management and outcome varied significantly by insurance status despite adjustment for potential confounders. Providers might need to heighten surveillance for complications when treating patients without private insurance to improve outcome. © 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.Colorectal Disease 10/2012; 15(5). DOI:10.1111/codi.12066 · 2.02 Impact Factor