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Demographic, educational factors influence Massachusetts CV care after health care reforms
Health care reform in Massachusetts has reduced patient barriers to coronary revascularization, but the frequency and outcomes of these procedures continue to be influenced by socioeconomic factors, according to a new report.
Researchers conducted a study to compare differences in rates of coronary revascularization, including PCI or CABG, as well as in-hospital and 1-year postprocedure mortality. The study included 24,216 Massachusetts residents aged 21 to 64 years who were hospitalized for ischemic heart disease before (Nov. 1, 2004, to July 31, 2006; n=24,216) and after (Dec. 1, 2006, to Sept. 30, 2008; n=20,721) implementation of health care reform in Massachusetts. The cohort was 82% white, 4.1% black, 4.8% Hispanic and 1.3% Asian, and was predominantly male (25.4% female), with a mean age of 54.4 years.
PCI was performed significantly less frequently in the post-reform period (22.3% of cases vs. 27.2% of cases; P<.001). The same trend was observed for CABG in the post-reform period (5.8% of cases vs. 6.3% of cases; P=.013).
Before health care reform, black residents were 30% less likely than white residents to undergo coronary revascularization. After reform, the OR for revascularization was 0.73 (95% CI, 0.63-0.84) for black residents and 0.84 (95% CI, 0.74-0.97) for Hispanic residents vs. white residents. Asian residents were more likely than white residents to undergo revascularization after reform (OR=1.29; 95% CI, 1.01-1.65).
Other factors linked to increased likelihood of coronary revascularization both before and after reform included male sex (adjusted OR=0.54; 95% CI, 0.51-0.58), private insurance (OR=0.56, 95% CI, 0.52-0.6 for public insurance; OR=0.56; 95% CI, 0.42-0.75 for self-pay insurance) and living in a community with a greater number of high school graduates (OR=0.71; 95% CI, 0.66-0.77 for <79.6% high school graduates vs. >88.6%).
The researchers also noted that the adjusted risk for in-hospital mortality was higher among patients in areas with a lower high school graduation rate after reform compared with before reform. The mortality rate at 1 year after revascularization did not differ between the two time periods according to race/ethnicity, sex or education level, but was significantly greater among residents with self-pay insurance (OR=5.89; 95% CI, 2.45-14.1) or public insurance (OR=2.32; 95% CI, 1.76-3.07) vs. private insurance.
“Although near-universal insurance has been achieved in Massachusetts, disparities in the performance of coronary revascularization procedures persist according to certain demographic characteristics,” the researchers concluded. “… Our results underscore the need for continued work that focuses on residual factors related to health disparities and implementation of interventions aimed at assessing and addressing specific needs of vulnerable subgroups as part of the health care reform process.”
Disclosure: The researchers report no relevant financial disclosures.