Money prevents patients from seeking timely heart care

by Crystal Phend

Lack of insurance and financial concerns keep patients from treating a heart attack like the emergency it is, researchers affirmed.

A delay in getting to the hospital for treatment of acute MI was 38% more likely among the uninsured and 21% more likely among insured patients with financial concerns, reported Paul S. Chan, MD, MSc, Mid America Heart Institute in Kansas City, Mo., and colleagues.

More than two in every five heart attack patients in the study fit into these two groups, they wrote in the April 14 issue of the Journal of the American Medical Association.

This despite the fact that patients cannot be turned away for emergency care regardless of ability to pay, the researchers said.

Delays in seeking treatment likely apply to other common conditions that require urgent attention too, such as stroke, pneumonia, and appendicitis, the researchers suggested.

More than half of the insured patients with financial concerns that kept them from pursuing timely care had either fee-for-service or health maintenance organization insurance plans, Chan’s group reported.

“Thus, having private healthcare insurance did not guarantee use of healthcare services that were essential for these patients, perhaps because they perceived them as unaffordable in the face of competing financial demands,” they wrote.

In fact, it was surprising that having insurance wasn’t a bigger factor than it was in the study, commented Timothy Henry, MD, of the Minneapolis Heart Institute at Abbott Northwestern Hospital in Minneapolis.

His group has studied the effect of insurance status and other factors on MI treatment once patients enter the hospital.

“Over the last five to 10 years we’ve done a terrific job of improving time to treatment once you make it to the hospital,” he said. “But the area that’s been very difficult to improve upon is the time it takes the patient from the onset of chest pain to actually go to the hospital.”

In a prepared statement, Ralph G. Brindis, MD, MPH, president of the American College of Cardiology, noted that “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 called the new healthcare reform law an opportunity to address this disparity.

Chan and colleagues’ Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status (TRIUMPH) study included 3,721 acute MI patients who entered a registry at one of 24 American hospitals between April 11, 2005, and Dec. 31, 2008.

Medical records supplemented by structured interviews indicated that 61.7% of the patients treated during this period carried insurance and did not have financial concerns about their care.

Another 19.8% were uninsured, and 18.5% were insured but had financial concerns about accessing care, indicated by the fact that they reported having avoided medical care in the prior year, nonadherence to medications in the prior year, or current difficulty obtaining healthcare services.

There were delays of more than six hours between onset of symptoms of acute MI and hospital presentation among 48.6% of uninsured patients and 44.6% of those who were insured but had financial concerns compared with 39.3% of insured patients without financial concerns.

These long delays lowered the likelihood of primary reperfusion therapy with either thrombolytics or percutaneous coronary intervention (P=0.002).

Conversely, the adequately insured, unworried patients were most likely to have less than a two hour delay in presentation (36.6%) compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients.

These delays likely increased the morbidity and mortality of acute MI, said Henry, who was not involved in the study.

However, the study included non-ST segment elevation MI along with the more time-sensitive ST segment elevation MI, he noted.

But sensitivity analyses and adjustment for demographics, clinical comorbidities, acute MI characteristics, baseline health status, social factors, and psychosocial variables did not eliminate the associations.

Further research is needed to determine “whether and which aspects of underinsurance — high out-of-pocket healthcare costs (copayments, coinsurance, deductibles), low lifetime health benefit ceilings, or lack of catastrophic or stop-loss provisions — may be responsible for perceived cost burden,” Chan’s group concluded in the JAMA paper.

They cautioned that the study did not have a mechanism to validate the delay times reported in medical records (missing in 12% of cases) or to directly assess underinsurance or other financial factors for patients.

Residual confounding by factors not included in the study, such as distance to the hospital and traffic patterns, may have been a limitation as well, they said.

Furthermore, almost 40% of insured patients without financial concerns also delayed in getting to the hospital by more than six hours, the investigators noted.

“This suggests that other patient factors accounted for prehospital delays,” they wrote in the study. “Improving health insurance coverage, while important, is but one component in a comprehensive strategy to reduce times to hospital presentation during acute MI.”

Henry and Brindis agreed that there are other major factors that can be tackled, particularly through patient education.

Crystal Phend is a MedPage Today Senior Staff Writer.

Originally published in MedPage Today. Visit MedPageToday.com for more cardiology news.

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