Association of health insurance status with presentation and outcomes of coronary artery disease among nonelderly adults undergoing percutaneous coronary intervention

doi:10.1016/j.ahj.2011.06.002

American Heart Journal

Volume 162, Issue 3, September 2011, Pages 512-517

https://doi.org/10.1016/j.ahj.2011.06.002 Get rights and content

Objective

The aim of this study was to determine if insurance status is associated with adverse outcomes in patients with coronary artery disease.

Methods

A cohort of 13,456 patients who underwent percutaneous coronary intervention (PCI) between January 1, 2004, and December 31, 2007, at 4 New York State teaching hospitals was retrospectively studied. The primary outcome of interest was in-hospital mortality from any cause.

Results

Of the 13,456 patients studied, 11,927 (88.6%) were insured by private carriers, 1,036 (7.7%) patients were covered by Medicaid, and 493 (3.7%) were uninsured. Uninsured and Medicaid patients tended to be younger and more often nonwhite and Hispanic. They had a higher prevalence of congestive heart failure and worse left ventricular function. Compared with privately insured patients, uninsured and Medicaid patients had increased all-cause mortality (1.2% and 0.9%, respectively, vs 0.3%; P < .001). For all patients, lack of insurance (OR 3.02, 95% CI 1.10-8.28) and Medicaid (OR 4.39, 95% CI 1.93-9.99) were independently associated with mortality. Lack of insurance (OR 5.02, 95% CI 1.58-15.93) and Medicaid (OR 4.55, 95% CI 1.19-17.45) were also independently associated with increased mortality in patients undergoing emergent PCI.

Conclusion

Lack of insurance and Medicaid insurance are both independently associated with an increased risk of in-hospital mortality after PCI for coronary artery disease.

Section snippets

Study design

Data were collected from all patients who underwent PCI between January 1, 2004, and December 31, 2007, at 4 New York State academic medical centers. Data elements included patient demographic information; insurance status; baseline clinical, angiographic, and procedural characteristics; as well as in-hospital outcomes. To protect the anonymity of patients, all data were stripped of 20 potential identifiers by each individual center and submitted to a central databank for analysis. The

Results

Among 13,456 patients analyzed, 11,927 (88.6%) were covered by private insurance, 1,036 (7.7%) were covered by Medicaid, and 493 (3.7%) were designated as uninsured. Of the privately insured patients, 6,468 (54.2%) were enrolled in fee-for-service plans, whereas 5,429 (45.8%) were covered by managed care plans, and 646 (62.4%) and 390 (37.6%) of the Medicaid-insured patients were covered by fee-for service and managed care plans, respectively. Baseline demographic data and medical history are

Comment

The significant findings of this retrospective cohort study in which all patients underwent PCI for CAD are 2-fold. First, uninsured and Medicaid patients present more often at a younger age, with an acute coronary syndrome, with more advanced CAD for age, and with a greater degree of left ventricular dysfunction than do patients with private insurance. Second, after multivariable risk adjustment, lack of insurance and Medicaid coverage are both independently associated with an increased risk

Conclusions

In this observational analysis, uninsured or Medicaid insurance status was independently associated with a 3- to 4-fold increased risk of in-hospital mortality in patients undergoing PCI for CAD. Clinical outcomes may be improved by eliminating financial barriers and ensuring unimpeded access to outpatient health care for uninsured and underinsured individuals.

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Effect of Insurance Status on Outcomes of Acute Ischemic Stroke Patients Receiving Intra-Arterial Treatment: Results from the Paul Coverdell National Acute Stroke Program
2021, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
The question remains whether insurance status has further impact on outcomes after the delivery of IAT. For instance, uninsured or Medicaid patients undergoing coronary reperfusion treatments are more likely to suffer in-hospital death as a result of more advanced chronic medical conditions.9 We use a multistate stroke registry to examine the effect of insurance status on outcomes for AIS patients who receive IAT.
Stroke continues to be a leading cause of death and disability in the United States. Rates of intra-arterial reperfusion treatments (IAT) for acute ischemic stroke (AIS) are increasing, and these treatments are associated with more favorable outcomes. We sought to examine the effect of insurance status on outcomes for AIS patients receiving IAT within a multistate stroke registry.
We used data from the Paul Coverdell National Acute Stroke Program (PCNASP) from 2014 to 2019 to quantify rates of IAT (with or without intravenous thrombolysis) after AIS. We modeled outcomes based on insurance status: private, Medicare, Medicaid, or no insurance. Outcomes were defined as rates of discharge to home, in-hospital death, symptomatic intracranial hemorrhage (sICH), or life-threatening hemorrhage during hospitalization.
During the study period, there were 486,180 patients with a clinical diagnosis of AIS (mean age 70.6 years, 50.3% male) from 674 participating hospitals in PCNASP. Only 4.3% of patients received any IAT. As compared to private insurance, uninsured patients receiving any IAT were more likely to experience in-hospital death (AOR 1.36 [95% CI 1.07–1.73]). Medicare (AOR 0.78 [95% CI 0.71–0.85]) and Medicaid (AOR 0.85 [95% CI 0.75–0.96]) beneficiaries were less likely but uninsured patients were more likely (AOR 1.90 [95% CI 1.61–2.24]) to be discharged home. Insurance status was not found to be independently associated with rates of sICH.
Insurance status was independently associated with in-hospital death and discharge to home among AIS patients undergoing IAT.
Association between insurance status, anticoagulation quality, and clinical outcomes in patients with acute venous thromboembolism
2019, Thrombosis Research
Citation Excerpt :
However, even among patients with insurance coverage, the level (intensity) of coverage may also be related to processes of care and patient outcomes. Evidence suggests that a higher level of health insurance coverage may be associated with better access to healthcare, quality of care, and outcomes in patients with cardiorespiratory disorders, such as heart failure [4], acute coronary syndrome [5,6], chronic asthma [7], and COPD [8,9]. Switzerland is a country with mandatory health care coverage, which offers a universal access to health care [10].
A higher level of health insurance coverage may be related to better quality of care and outcomes. Whether insurance status is associated with anticoagulation quality and clinical outcomes in patients with venous thromboembolism (VTE) is unknown.
We studied 819 elderly patients treated with vitamin K antagonists for VTE in a Swiss prospective multicenter cohort (09/2009–12/2013). The study outcomes were the anticoagulation quality, defined as the time spent in the therapeutic INR range, and clinical events, i.e. the time to a first VTE recurrence, major bleeding, and mortality. We assessed the association between insurance status (private vs. general), anticoagulation quality, and clinical outcomes using regression models, adjusting for potential confounders.
Although the unadjusted mean percentage of time spent in the therapeutic INR range (2.0–3.0) was slightly higher in patients with private vs. general insurance (65% vs. 61%; p = 0.030), the adjusted difference was not statistically significant (1.53%, 95% CI −1.97 to 5.04). Patients with private insurance had a lower 36-month cumulative incidence of major bleeding (9.7% vs. 15.7%; p = 0.018). After adjustment, privately insured patients had a lower risk of major bleeding compared to patients with general insurance (sub-hazard ratio 0.57, 95% CI 0.32 to 0.98). Insurance status was not associated with recurrent VTE or mortality.
Privately insured patients spent somewhat more time in therapeutic INR range and had a lower rate of major bleeding than generally insured patients. Basic (general) health insurance may be a marker of lower anticoagulation quality and higher risk of major bleeding.
Association Between Health Insurance Status and In-Hospital Outcomes After ST-Segment Elevation Myocardial Infarction
2017, American Journal of Cardiology
Lack of health insurance is associated with adverse clinical outcomes; however, association between health insurance status and outcomes in patients presenting with ST-elevation myocardial infarction (STEMI) is unclear. Using the Nationwide Inpatient Sample data from 2003 to 2014, hospitalizations with STEMI in patients 18 years of age and older were extracted. Based on health insurance status, patients were categorized into insured and uninsured groups. The primary outcome measure was in-hospital mortality. Adjusted analysis using inverse probability weighting with multivariable regression was performed to identify independent predictors of in-hospital mortality. Of 2,710,375 patients included in the final analysis, 220,770 patients were uninsured. Unadjusted in-hospital mortality was lower in uninsured patients (5.1% vs 9.3%; p <0.001). Adjusted analysis showed that lack of health insurance was associated with the worst in-hospital mortality (odds ratio [OR] = 1.77, 95% confidence interval [CI] 1.72 to 1.82; p <0.001). Other independent predictors of in-hospital mortality were low household income (OR = 1.08, 95% CI 1.07 to 1.09; p <0.001), acute stroke (OR = 2.87, 95% CI 2.80 to 2.95; p <0.001), acute kidney injury (OR = 2.60, 95% CI 2.57 to 2.64; p <0.001), cardiac arrest (OR = 8.88, 95% CI 8.77 to 8.99; p <0.001), cardiogenic shock (OR = 5.81, 95% CI 5.74 to 5.88; p <0.001), requirement of pericardiocentesis (OR = 10.54, 95% CI 9.64 to 11.52; p <0.001), gastrointestinal bleeding (OR = 1.41, 95% CI 1.38 to 1.54; p <0.001), and pneumonia (OR = 1.43, 95% CI 1.41 to 1.45; p <0.001). The multivariate model demonstrated good statistical discrimination (c-statistic = 0.89). In conclusion, lack of health insurance is independently associated with increased in-hospital mortality in patients presenting with STEMI.
In-Hospital Outcomes of Percutaneous Coronary Intervention in America's Safety Net: Insights From the NCDR Cath-PCI Registry
2017, JACC: Cardiovascular Interventions
Citation Excerpt :
In 2011, a study from the Washington Hospital Center examining a 10-year experience of PCI found that uninsured patients had a higher rate of risk-adjusted cardiac events (composite of death, Q-wave myocardial infarction, and target vessel revascularization) at 1 year when compared with patients with private insurance (10). Similarly, an analysis of a contemporary PCI cohort from 4 New York teaching hospitals showed an increased risk of in-hospital mortality among patients without insurance or with Medicaid (11). The causes of these differences in outcome are unclear.
This study compared risk-adjusted percutaneous coronary intervention (PCI) outcomes of safety-net hospitals (SNHs) and non-SNHs.
Although risk adjustment is used to compare hospitals, SNHs treat a disproportionate share of uninsured and underinsured patients, who may have unmeasured risk factors, limited health care access, and poorer outcomes than patients treated at non-SNHs.
Using the National Cardiovascular Data Registry CathPCI Registry from 2009 to 2015, we analyzed 3,746,961 patients who underwent PCI at 282 SNHs (hospitals where ≥10% of PCI patients were uninsured) and 1,134 non-SNHs. The relationship between SNH status and risk-adjusted outcomes was assessed.
SNHs were more likely to be lower volume, rural hospitals located in the southern states. Patients treated at SNHs were younger (63 vs. 65 years), more often nonwhite (17% vs. 12%), smokers (33% vs. 26%), and more likely to be admitted through the emergency department (48% vs. 38%) and to have an ST-segment elevation myocardial infarction (20% vs. 14%) than non-SNHs (all p < 0.001). Patients undergoing PCI at SNHs had higher risk-adjusted in-hospital mortality (odds ratio: 1.23; 95% confidence interval: 1.17 to 1.32; p < 0.001), although the absolute risk difference between groups was small (0.4%). Risk-adjusted bleeding (odds ratio: 1.05; 95% confidence interval: 1.00 to 1.12; p = 0.062) and acute kidney injury rates (odds ratio: 1.01; 95% confidence interval: 0.96 to 1.07; p = 0.51) were similar.
Despite treating a higher proportion of uninsured patients with more acute presentations, risk-adjusted PCI-related in-hospital mortality of SNHs is only marginally higher (4 additional deaths per 1,000 PCI cases) than non-SNHs, whereas risk-adjusted bleeding and acute kidney injury rates are comparable.
Insurance status by region at the time of heart transplantation: Implications for survival
2016, Journal of Heart and Lung Transplantation
Heart transplantation outcomes differ by health insurance status and geographic region of the United States. We hypothesized that heart transplantation survival would be affected by health insurance status within certain United Network for Organ Sharing (UNOS) regions.
We used data from the UNOS thoracic database to classify health insurance status into private or public (private/self-pay or Medicare/Medicaid) for all first-time heart transplant recipients between July 2006 and September 2013. We applied Cox proportional hazards regression to estimate hazard ratio (HR) and 95% confidence interval (CI) for the influences of health insurance status on 1-year and long-term survival in heart transplant recipients by UNOS region.
Mean survival time among 10,474 patients was 942 days ± 704. All key demographic and clinical variables varied significantly across UNOS regions. With respect to 1-year survival, patients in Region 2 had a higher hazard of mortality (HR, 1.49; 95% CI, 1.03, 2.15) if they had public vs private insurance. When we restricted the analysis to be conditional on 1-year survival, 2 contiguous regions, Region 10, including Indiana, Ohio, Michigan (HR, 2.30; 95% CI, 1.23, 4.28), and Region 11 (HR, 1.85; 95% CI, 1.15, 2.97), including the upper South, had poor survival associated with public vs private insurance.
The data we present invite targeted efforts by certain UNOS regions to improve the standard of care and/or eligibility thresholds for heart transplant recipients.
Variation in access to pediatric surgical care among coexisting public and private providers: Inguinal hernia as a model
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View full text

Clinical InvestigationInterventional CardiologyAssociation of health insurance status with presentation and outcomes of coronary artery disease among nonelderly adults undergoing percutaneous coronary intervention

Objective

Methods

Results

Conclusion

Section snippets

Study design

Results

Comment

Conclusions

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

ACCF/AHA 2009 performance measures for primary prevention of cardiovascular disease in adults: a report of the American College of Cardiology Foundation/American Heart Association task force on performance measures

Circulation

Unmet health needs of uninsured adults in the United States

JAMA

Care denied: US residents who are unable to obtain needed medical services

Am J Public Health

Risk of cardiovascular events and death—does insurance matter?

J Gen Intern Med

Clinical Investigation
Interventional Cardiology
Association of health insurance status with presentation and outcomes of coronary artery disease among nonelderly adults undergoing percutaneous coronary intervention