Insurance Coverage and Care of Patients with Non–ST-Segment Elevation Acute Coronary Syndromes

21 November 2006 | Volume 145 Issue 10 | Pages 739-748

Background: The impact of insurance coverage on the care of patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear.

Objective: To compare NSTE ACS care patterns by insurance type.

Design: 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.

Setting: 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.

Patients: 37 345 NSTE ACS patients younger than 65 years of age and 59 550 patients 65 years of age or older.

Measurements: Guideline-recommended treatments, and in-hospital outcomes.

Results: 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).

Limitations: Self-pay patients and patients without insurance were not assessed.

Conclusions: 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.

Editors' Notes Context Medicaid and Medicare reimbursement is typically lower than that of private insurance. This might affect access to care for Medicaid and Medicare patients. Contribution The authors studied the care received for non–ST-segment elevation acute coronary syndromes by 37 345 patients younger than age 65 years and 59 550 patients age 65 years or older. Compared with privately insured patients, Medicaid patients received fewer guideline-recommended services at admission or discharge and experienced greater delays in receiving invasive procedures. Differences for Medicare patients were fewer and smaller, although delays were common. The in-hospital mortality rate was higher in Medicaid patients but not Medicare patients. Cautions The authors could not assess the appropriateness of invasive procedures, socioeconomic status, severity of comorbid conditions, or patient preferences. —The Editors

 

Author and Article Information

From Rush University Medical Center, Chicago, Illinois; Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina; North Shore University Hospital, Long Island, New York; Northwestern University Hospital, Chicago, Illinois; University of Cincinnati School of Medicine, Cincinnati, Ohio; and the University of North Carolina School of Medicine, Chapel Hill, North Carolina.

Grant Support: CRUSADE is funded by Schering-Plough Corporation. Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals Partnership provides additional funding support. Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, also provided funding for this research.

Potential Financial Conflicts of Interest:Consultancies: M.T. Roe (Schering-Plough, Bristol-Myers Squibb, Sanofi), E.M. Ohman (Savacor, Liposcience, Responsible Biomedical, The Medicines Company, Inovise): Honoraria: J.E. Calvin (Millenium Speaker's Bureau), M.T. Roe (Sanofi, Bristol-Myers Squibb, Schering-Plough); Stock ownership or options (other than mutual funds): E.M. Ohman (Inovise, Savacor, Medtronics Inc.); Grants received: M.T. Roe (Schering-Plough, Bristol-Myers Squibb), W.B. Gibler (Schering-Plough, Bristol-Myers Squibb, Sanofi-Aventis), E.M. Ohman (Bristol-Myers Squibb, Sanofi-Aventis, Schering-Plough, Millenium Pharmaceuticals, Eli Lilly Inc., Berlex).

Requests for Single Reprints: James E. Calvin, MD, Section of Cardiology, Rush University Medical Center, 1653 West Congress Parkway, Room 1021-Jelke SC, Chicago, IL 60612; e-mail, James_Calvin{at}rush.edu.

Current Author Addresses: Dr. Calvin: Section of Cardiology, Rush University Medical Center, 1653 West Congress Parkway, Room 1021-Jelke SC, Chicago, IL 60612.

Drs. Roe and Peterson: Division of Cardiology, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705.

Ms. Chen and Drs. Mehta and DeLong: Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705.

Dr. Brogan: Department of Emergency Medicine, New York University School of Medicine, North Shore Long Island Jewish Health System, Plainview, NY 11803.

Dr. Fintel: Coronary Care Unit, Northwestern University School of Medicine, Wesley Suite 726, 250 East Superior Street, Chicago, IL 60611.

Dr. Gibler: Department of Emergency Medicine, University of Cincinnati College of Medicine, Mail Location 0769, 231 Albert Sabin Way, Cincinnati, OH 45267-0769.

Dr. Ohman: Division of Cardiology, Duke University Medical Center, Room 7403 Duke Hospital North, Box 3126 DUMC, Durham, NC 27705.

Dr. Smith: Center for Cardiovascular Science and Medicine, The University of North Carolina at Chapel Hill, CB #7075, 6th Floor, Burnett-Womack Building, 99 Manning Drive, Chapel Hill, NC 27599-7075.

Author Contributions: Conception and design: S.C. Smith, J.E. Calvin, M.T. Roe, W.B. Gibler, E.D. Peterson, E.M. Ohman.

Analysis and interpretation of the data: M.T. Roe, A.Y. Chen, E.D. Peterson, E.M. Ohman.

Drafting of the article: J.E. Calvin, R.H. Mehta, E.D. Peterson.

Critical revision of the article for important intellectual content: S.C. Smith, J.E. Calvin, M.T. Roe, R.H. Mehta, G.X. Brogan, E.R. DeLong, D.J. Fintel, W.B. Gibler, E.D. Peterson, E.M. Ohman.

Final approval of the article: S.C. Smith, J.E. Calvin, M.T. Roe, R.H. Mehta, G.X. Brogan, E.R. DeLong, D.J. Fintel, W.B. Gibler, E.D. Peterson, E.M. Ohman.

Provision of study materials or patients: E.D. Peterson.

Statistical expertise: M.T. Roe, A.Y. Chen, E.R. DeLong, E.D. Peterson.

Obtaining of funding: E.D. Peterson, E.M. Ohman.

Administrative, technical, or logistic support: E.D. Peterson, E.M. Ohman.

Collection and assembly of data: E.D. Peterson.

Read all Rapid Responses

Insurance Coverage and Care of Patients with non-ST-Segment Elevation Acute Coronary Syndromes

Joseph S. Ross

Annals Online, 13 Dec 2006 [Full text]

In Response

James E. Calvin, et al.

Annals Online, 8 Jan 2007 [Full text]