Disparities by insurance status in quality of care for elderly patients with unstable angina.
BACKGROUND
Treatment disparities for socioeconomically disadvantaged populations have been widely reported, but few studies have sought explanations for these disparities.


OBJECTIVE
To compare the quality of care for patients insured by Medicare alone, Medicare plus Medicaid, or Medicare plus private insurance and investigate mediators for potential disparities.


METHODS
Retrospective, random chart review of 3122 African American or White Medicare patients >65 years of age hospitalized for unstable angina in 22 Alabama hospitals, 1993-1999.


METHODS
Echocardiogram within 20 minutes of presentation; evaluation by a cardiologist; appropriate anti-platelet therapy within 24 hours of admission and at discharge, heparin for high-risk patients, beta-blockers during hospitalization, and performance of appropriate coronary angiography.


RESULTS
182 (5.8%) had Medicare only, 433 (13.9%) had Medicare plus Medicaid, and 2507 (80.3%) had Medicare plus private insurance. Medicaid patients were more frequently Black, female, >85 years old, had multiple co-morbidities, or were admitted to hospitals without cardiac catheterization facilities (P<.001). Fewer Medicaid patients were admitted to hospitals with cardiac catheterization capabilities. Even after adjustment for demographics and hospital characteristics, Medicaid patients were less likely to see a cardiologist (odds ratio [OR] .57, 95% confidence interval [CI] .44-.73), receive antiplatelet therapy within 24 hours of admission (OR .66, 95% CI .50-.87), or heparin (OR .71, 95% CI .53-.97). No differences were seen with regard to having an electrocardiogram within 20 minutes of admission. Beta-blockers were used least in the Medicare-only patients, with only 37.7% receiving them (P=.04). Suitable Medicaid patients received coronary angiography less often, even after adjustment for demographics, co-morbidity, and prior revascularization (OR .68, 95% CI .48-.97). However, when adjusted for hospital characteristics, this finding was no longer observed (OR .94, 95% CI .64-1.39).


CONCLUSIONS
Elderly Medicaid patients appear to receive poorer quality of care. This finding is partially, but not completely, explained by characteristics of the facilities where they are hospitalized.
Pamboukian
Salpy V
SV
Division of Cardiovascular Disease, The University of Alabama at Birmingham, Birmingham 35294, USA. spamboukian@cardmail.dom.uab.edu
Funkhouser
Ellen
E
Child
Ian G
IG
Allison
Jeroan J
JJ
Weissman
Norman W
NW
Kiefe
Catarina I
CI
D000319:Adrenergic beta-Antagonists / Q000191:economics / Q000627:therapeutic use; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D000407:Alabama / Q000453:epidemiology; D000789:Angina, Unstable / Q000175:diagnosis / Q000191:economics* / Q000208:ethnology / Q000628:therapy; D006328:Cardiac Catheterization / Q000191:economics; D002309:Cardiology / Q000191:economics; D015986:Confounding Factors, Epidemiologic; D017023:Coronary Angiography / Q000191:economics; D004452:Echocardiography / Q000191:economics; D004562:Electrocardiography / Q000191:economics; D018588:Fee-for-Service Plans / Q000191:economics; D005260:Female; D005343:Fibrinolytic Agents / Q000191:economics / Q000627:therapeutic use; D006299:Health Services for the Aged / Q000191:economics; D006493:Heparin / Q000191:economics / Q000627:therapeutic use; D006760:Hospitalization / Q000191:economics; D006801:Humans; D019458:Insurance Coverage; D008297:Male; D008484:Medicaid / Q000592:standards; D006278:Medicare / Q000592:standards; D016017:Odds Ratio; D010975:Platelet Aggregation Inhibitors / Q000191:economics / Q000627:therapeutic use; D011787:Quality of Health Care / Q000191:economics*; D012189:Retrospective Studies; D035862:Vulnerable Populations; D044465:White People / Q000706:statistics & numerical data
D000319:Adrenergic beta-Antagonists; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D006493:Heparin