Elsevier

American Heart Journal

Volume 159, Issue 6, June 2010, Pages 1026-1036
American Heart Journal

Clinical Investigation
Coronary Artery Disease
Association of insurance status with inpatient treatment for coronary artery disease: Findings from the Get With the Guidelines program

https://doi.org/10.1016/j.ahj.2010.03.013Get rights and content

Background

Prior studies have documented that patients' health insurance status can impact use of guideline-based care as well as acute outcomes for coronary artery disease. Whether insurance status remains a contemporary influence among centers participating in a national quality improvement initiative is unknown.

Methods

We analyzed data from 237,779 admissions with coronary artery disease from 527 hospitals participating in the Get With The Guidelines-Coronary Artery Disease Program from 2000 to 2008. Insurance status was Medicare (48.8%), Private/Health Maintenance Organization (HMO) (34.9%), Medicaid (8.2%), and No Insurance Documented (NID) (8.2%). Quality of care was measured using standard quality indicators covering acute treatment and discharge measures, utilization of invasive procedures, length of stay, and mortality. Relationship between different insurance types was examined using generalized estimating equation logistic regression and propensity-score matching adjusting for demographics, comorbidities and hospital characteristics.

Results

After propensity matching, full compliance with all eligible measures (deficit-free care) relative to Private/HMO was lower for Medicare (P < .0001) and Medicaid (P < .0001) and higher for the NID group (P = .0312). The acute reperfusion times were comparable among the groups. Compared with the Private/HMO group, all three groups had higher generalized estimating equation–adjusted mortality (OR, 1.15; 95% CI, 1.08-1.21; P < .001; OR, 1.18; 95% CI, 1.09-1.29; P < .001 and OR, 1.13; 95% CI, 1.01-1.25; P = .026), for Medicare, Medicaid, and NID, respectively. After propensity matching, mortality for Medicare was similar (P = .1197) and higher for NID (P = .0015) and Medicaid (P = .0015) groups.

Conclusions

These findings suggest that among centers participating in a national quality improvement initiative patient insurance status may be associated with differences in cardiovascular care and outcomes.

Section snippets

Data collection

The GWTG-CAD quality initiative is a hospital-based program that relies on a multidisciplinary team consisting of nurses, physicians, quality improvement staff, administrative leaders and other allied health professionals as previously described.10 It includes didactic sessions, best practice sharing, interactive workshops, and a Web-based patient management tool (Outcome Sciences Inc, Cambridge, Massachusetts).11 This patient management tool provides concurrent data collection, clinical

Patient characteristics

Of all admissions for CAD (n = 237,779), insurance status was Medicare (48.8%), Private/Health Maintenance Organization (HMO) (34.9%), Medicaid (8.2%), and No Insurance Documented (NID) (8.2%). Baseline characteristics for the 4 groups are listed in Table I. Medicare patients were older than the other groups while patients with Private/HMO and NID insurance status were younger and >70% male. Medicaid patients were more likely black or Hispanic. The differences among the groups in blood

Discussion

Despite major advances in the last 2 decades in prevention and treatment of CAD and MI, access to evidence-based care in the United States may be limited by patients' insurance status. Lack of insurance may influence access to and delivery of care in both the inpatient and outpatient environment. Insurance status may bias health care providers and prevent patients from receiving appropriate care.14 Our results indicate that among GWTG-CAD participating hospitals patients with Medicare and

Disclosures

MIV: Honoraria — Eli Lilly, Daiichi Sankyo, Medicure <$10,000

SV: none

CPC: Research Grant—Accumetrics, AstraZeneca, Bristol-Myers Squibb/Sanofi Partnership, Glaxo Smith Kline, Merck, Merck/Schering Plough Partnership >$10,000; Expert Witness—one case in Virginia >$10,000, one ongoing case in Michigan <$10,000; Ownership Interest—Automedics Medical Systems <$10,000, Consultant/Advisory Board—Automedics <$10,000; Other disclosures—Senior Investigator, TIMI Study Group, $ = N/A

EDP: Research

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