Title: Health Care Insurance, Financial Concerns in Accessing Care, and Delays to Hospital Presentation in Acute Myocardial Infarction
Topic: General Cardiology
Date Posted: 4/13/2010 4:00:00 PM
Author(s): Smolderen KG, Spertus JA, Nallamothu BK.
Citation: JAMA 2010;303:1392-1400.
Clinical Trial: No
Study Question: What is the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during acute myocardial infarction (AMI)?
Methods: This was a multicenter, prospective study using a registry of 3,721 AMI patients enrolled between April 2005, and December 2008, at 24 US hospitals. Health insurance status was categorized as: insured without financial concerns, insured but have financial concerns about accessing care, and uninsured. Insurance information was determined from medical records, while financial concerns among those with health insurance were determined from structured interviews. The primary outcome measure was prehospital delay times (≤2 hours, >2-6 hours, or >6 hours), adjusted for demographic, clinical, and social and psychological factors using hierarchical ordinal regression models.
Results: Of 3,721 patients, 2,294 were insured without financial concerns (61.7%), 689 were insured but had financial concerns about accessing care (18.5%), and 738 were uninsured (19.8%). Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI and had prehospital delays of greater than 6 hours among 48.6% of uninsured patients and 44.6% of insured patients with financial concerns compared with only 39.3% of insured patients without financial concerns. Prehospital delays of less than 2 hours during AMI occurred among 36.6% of those insured without financial concerns compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients (p < 0.001). After adjusting for potential confounders, prehospital delays were associated with insured patients with financial concerns (adjusted odds ratio, 1.21; 95% confidence interval, 1.05-1.41; p = 0.01) and with uninsured patients (adjusted odds ratio, 1.38; 95% confidence interval, 1.17-1.63; p < 0.001).
Conclusions: The authors concluded that lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.
Perspective: The authors found that uninsured patients and insured patients with financial concerns about accessing medical treatment were more likely to delay seeking emergency care for AMI, a common presentation of coronary artery disease. These findings underscore important consequences from inadequate or absent health care insurance coverage for the substantial number of individuals in the United States experiencing AMIs. Efforts to reduce prehospital delays for AMI and other emergency conditions may have only limited benefit unless US health care insurance coverage is extended and improved. If financial concern about the cost of care can be eliminated or ameliorated, patients are more likely to present in a timely manner. Debabrata Mukherjee, M.D., F.A.C.C.
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