To most physicians, the delay in hospital presentation seems far too long-and beyond their control. Most studies report that the median time from onset of symptoms to hospital presentation is between 2 and 6.5 hours [2-5]. The effect of public education campaigns aimed at reducing delay in presentation has been modest at best [6-9]. Concern has been raised that the growth of managed care will only make a bad situation worse because many managed care systems require patients to call their primary care physicians before going to the emergency department for non-life-threatening situations [10]. Anecdotal data suggest that this step introduces delay for some patients with acute myocardial infarction [11].

In this issue, Gurwitz and colleagues [2] provide reassurance about the impact of managed care and insight into the factors associated with delayed presentation. The authors analyzed data from 2409 patients admitted to 37 hospitals in Minnesota for acute myocardial infarction and found that 40% of patients presented to the hospital more than 6 hours after symptoms had developed. Factors associated with delayed presentation included female sex, advanced age, history of congestive heart failure, and occurrence of symptoms in the afternoon or at night.

The role of managed care is difficult to dissect from Gurwitz and colleagues' data because the penetration of health maintenance organizations is greater in Minnesota than in most states and because patients in such organizations were studied together with patients who had Medicare or commercial insurance. In this study, however, lack of insurance and having Medicaid as the primary health insurance were among the most powerful correlates of presentation more than 6 hours after the onset of symptoms.

These data and findings from other studies [3, 5] suggest that a multidimensional strategy is needed if meaningful improvements in survival after acute myocardial infarction are to be achieved by decreasing delay to presentation. Public education efforts about the symptoms and signs of heart attack should continue, but the "bang for the buck" might be increased if these educational interventions were targeted toward the subsets of patients most likely to have acute myocardial infarction and most likely to delay in seeking medical care. These subsets include the elderly, women, patients with risk factors for coronary disease, and patients with known cardiovascular disease.

For the individual clinician and the individual patient, these educational campaigns can be enhanced by improving understanding of the psychological and cultural factors that lead to delay in seeking medical attention [4, 12, 13]. Data indicate that patients who delay hospital presentation tend to be less comfortable seeking medical assistance and often perceive that they can control their own symptoms [4, 12]. Furthermore, unmarried patients respond significantly later than married patients, and patients whose symptoms develop at work tend to delay seeking help longer than those whose symptoms develop outside the home but in nonwork settings [12].

Managed care organizations have strong motivations to improve access and reduce delays in presentation among patients with acute myocardial infarction. These improvements can translate into a lower incidence of congestive heart failure and other complications, as well as greater patient satisfaction. Through the development of educational programs and teleservice centers, managed care organizations have the potential to improve access to care and information.

My sense, however, is that neither educational campaigns nor more personalized attention for individual patients can succeed in the absence of an effective health policy that addresses the high risk for delayed presentation among patients with inadequate health insurance. For these patients, the critical barriers to care are almost surely financial and logistical. If these factors remain beyond the control of individual physicians, they should be priorities in the improvement of health care delivery systems for society in general. An important challenge for the future is to find ways to place patients with no insurance or inadequate insurance into delivery systems that are wise enough to appreciate the importance of rapid access to care and effective enough to achieve it.