Cost concerns, health insurance status influenced emergency care decisions

People without health insurance and those who had insurance but were concerned about costs were more likely to delay care for acute MI, findings published online today indicated.

“These findings underscore important consequences from inadequate health care insurance coverage for the substantial number of individuals in the United States experiencing acute MIs,” the researchers wrote.

Researchers from several sites in the United States and the Netherlands assessed the association between health insurance and time from symptom onset to hospital arrival among 3,721 patients who experienced acute MI. Patients were enrolled at 24 U.S. hospitals between April 2005 and December 2008. Via medical records and structured patient interviews, the researchers categorized patients in one of three categories — those who were insured without financial concerns (61.7%), those who were insured but had financial concerns about accessing care (18.5%) and those who were uninsured (19.8%). Pre-hospital delay times were defined as two hours or less; between two and six hours; or more than six hours.

The researchers found that insured patients who did not have financial concerns were more likely to arrive at the hospital within two hours of symptom onset (36.6%) compared with those who had insurance and financial concerns (33.5%) and uninsured patients (27.5%; P<.001).

Also, 44.6% of insured patients who expressed financial concerns and 48.6% of uninsured patients arrived more than six hours after symptom onset vs. 39.3% of insured patients without financial worries. The association between pre-hospital delays, lack of insurance (adjusted OR=1.38; 95% CI, 1.17-1.63) and financial concern among insured patients (adjusted OR=1.21; 95% CI, 1.05-1.42) remained even after adjusting for various confounding factors.

The researchers noted that ensuring access to health insurance and improving financial concerns among patients who seek emergency care are essential to improve pre-hospital delay times.

“The real first step in successfully treating patients with MIs doesn’t occur at the hospital; it happens when patients seek care quickly,” American College of Cardiology president Ralph G. Brindis, MD, MPH, said in a press release. “Patients concerned over their ability to pay for treatment who delay seeking care are putting themselves at dire risk — the longer patients wait to seek care, the lower the chance for survival.”

Brindis added that health care reform is “a real opportunity” to improve patient outcomes among those with emergency conditions and to “reduce the stress that comes with having to choose between seeking treatment and maintaining financial stability.” – by Nicole Blazek and Eric Raible

Smolderen KG. JAMA. 2010;303:1392-1400.

This was an important and well-done study, and there are a few important issues the researchers addressed. One of these is that they did not just include STEMI, where time is the most important factor, but rather included both non-STEMI and STEMI. That was helpful. Another reason this study was good is that the researchers went into detail about the delays and made it clear what was going on once patients got to the hospital. Physicians cannot do much if you are not at the hospital.

Overall, 42% of patients had delays longer than six hours in getting to the hospital. To me, this indicated that insurance is just one aspect of why patients delay going to the hospital. Some of the results suggested that even with full insurance, almost 40% of the patients still waited an average of six hours. This suggested that the delay is far more complicated than just insurance status. The issue of delay is very important for the improvement of outcomes of patients with MI. The challenge for us is how we get the word out and encourage people to access care quickly.

In our center, we have developed a standardized approach that treats all patients the same regardless of whether they have insurance or not. We know that when you get to the hospital, there are no differences in the types of therapy provided or the time to treatment when you use that standardized protocol.

– Timothy Henry, MD
Director of Research,
Minneapolis Heart Institute Foundation
Abbott Northwestern Hospital, Minneapolis
Member, Society for Coronary Angiography and Interventions

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