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.
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- "The majority of Medicaid beneficiaries have incomes below the poverty line, thus, in the absence of other SES information, Medicaid coverage is a reasonable surrogate for low SES, and may be related to the receipt of evidence-based therapies following a MI. For example, acute coronary syndrome patients with Medicaid coverage were less likely to receive guideline-recommended medications and invasive cardiac procedures compared to patients of similar age with health maintenance organization or private insurance coverage. "
ABSTRACT: Pharmacologic treatments are efficacious in reducing post-myocardial infarction (MI) morbidity and mortality. The potential influence of socioeconomic factors on the receipt of pharmacologic therapy has not been systematically examined, even though healthcare utilization likely influences morbidity and mortality post-MI. This study aims to investigate the association between socioeconomic factors and receipt of evidence-based treatments post-MI in a community surveillance setting. We evaluated the association of census tract-level neighborhood household income (nINC) and Medicaid coverage with pharmacologic treatments (aspirin, beta [β]-blockers and angiotensin converting enzyme [ACE] inhibitors; optimal therapy, defined as receipt of two or more treatments) received during hospitalization or at discharge among 9,608 MI events in the ARIC community surveillance study (1993-2002). Prevalence ratios (PR, 95% CI), adjusted for the clustering of hospitalized MI events within census tracts and within patients, were estimated using Poisson regression. Seventy-eight percent of patients received optimal therapy. Low nINC was associated with a lower likelihood of receiving β-blockers (0.93, 0.87-0.98) and a higher likelihood of receiving ACE inhibitors (1.13, 1.04-1.22), compared to high nINC. Patients with Medicaid coverage were less likely to receive aspirin (0.92, 0.87-0.98), compared to patients without Medicaid coverage. These findings were independent of other key covariates. nINC and Medicaid coverage may be two of several socioeconomic factors influencing the complexities of medical care practice patterns.BMC Public Health 10/2010; 10:632. DOI:10.1186/1471-2458-10-632 · 2.32 Impact Factor
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- "The between-and within-hospital variables for race/ ethnicity and for payment source were substituted for the corresponding overall variables in the baseline model specification; otherwise the two specifications were identical. Calvin et al. (2006) use the same methodology to study the role of insurance in treatment patterns elsewhere. "
ABSTRACT: To quantify the variation in emergency department (ED) wait times by patient race/ethnicity and payment source, and to divide the overall association into between- and within-hospital components. 2005 and 2006 National Hospital Ambulatory Medical Care Surveys. Linear regression was used to analyze the independent associations between race/ethnicity, payment source, and ED wait times in a pooled cross-sectional design. A hybrid fixed effects specification was used to measure the between- and within-hospital components. Data were limited to children under 16 years presenting at EDs. Unadjusted and adjusted ED wait times were significantly longer for non-Hispanic black and Hispanic children than for non-Hispanic white children. Children in EDs with higher shares of non-Hispanic black and Hispanic children waited longer. Moreover, Hispanic children waited 10.4 percent longer than non-Hispanic white children when treated at the same hospital. ED wait times for children did not vary significantly by payment source. There are sizable racial/ethnic differences in children's ED wait times that can be attributed to both the racial/ethnic mix of children in EDs and to differential treatment by race/ethnicity inside the ED.Health Services Research 10/2009; 44(6):2022-39. DOI:10.1111/j.1475-6773.2009.01020.x · 2.49 Impact Factor
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ABSTRACT: The American College of Cardiology and American Heart Association publishes evidence-based guideline recommendations, yet the degree to which these guidelines are followed and the association between hospital guideline adherence and patient outcomes are unknown. Using data from 350 US centers participating in the "Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines" Quality Improvement Initiative, we evaluated the in-hospital treatment and outcomes from 64,775 patients with non-ST-segment elevation acute coronary syndromes. Overall, guideline-recommended treatments were followed in 74% of eligible instances. However, hospitals varied considerably in their composite adherence rates (median lowest to highest adherence hospital quartiles 63% to 82%). We also noted significant age, gender, and racial disparities in the use of guideline-recommended therapies as well as significant facility type and regional variability in care. Composite guideline adherence rates were significantly associated with in-hospital mortality. After risk adjustment, every 10% increase in composite adherence at a hospital was associated with a 10% reduction in its patients' likelihood of in-hospital mortality. Our findings support the use of broad, guideline-based performance metrics as a means of assessing and helping improve hospital quality.The Journal of cardiovascular nursing 01/2008; 23(1):50-5. DOI:10.1097/01.JCN.0000305058.03872.f1 · 1.81 Impact Factor