Insurance coverage and care of patients with non-ST-segment elevation acute coronary syndromes.
BACKGROUND
The impact of insurance coverage on the care of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear.


OBJECTIVE
To compare NSTE ACS care patterns by insurance type.


METHODS
Comparison of Medicaid patients younger than 65 years of age and Medicare patients 65 years of age or older with patients of similar age who have health maintenance organization (HMO) or private insurance coverage.


METHODS
521 U.S. hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC [American College of Cardiology]/AHA [American Heart Association] Guidelines) quality improvement initiative from January 2001 through March 2005.


METHODS
37,345 NSTE ACS patients younger than 65 years of age and 59,550 patients 65 years of age or older.


METHODS
Guideline-recommended treatments, and in-hospital outcomes.


RESULTS
Medicaid was the primary payer for 18.7% (6999 of 37,345) of patients younger than age 65 years, whereas Medicare was the primary payer for 67.5% (40,199 of 59,550) of patients age 65 years or older. Medicaid patients were statistically significantly less likely to receive short-term (less than 24 hours) medications and to undergo invasive cardiac procedures than patients covered by HMO and private insurance. They also had higher mortality rates (2.9% vs. 1.2%; adjusted odds ratio, 1.33; 95% CI, 1.08 to 1.63). Medications and invasive procedures were used to a similar extent in patients with Medicare and HMO or private insurance, and respective mortality rates were not significantly different (6.2% vs. 5.6%; adjusted odds ratio, 1.08; 95% CI, 0.99 to 1.18).


CONCLUSIONS
Self-pay patients and patients without insurance were not assessed.


CONCLUSIONS
NSTE ACS patients with Medicaid (but not Medicare) as the primary payer were less likely to receive evidence-based therapies and had worse outcomes than patients with HMO or private insurance as the primary payer. The causes of these treatment differences and solutions for narrowing the gaps in quality require further investigation.
Calvin
James E
JE
Section of Cardiology, Rush University Medical Center, Chicago, Illinois 60612, USA. James_Calvin@rush.edu
Roe
Matthew T
MT
Chen
Anita Y
AY
Mehta
Rajendra H
RH
Brogan
Gerard X
GX
Delong
Elizabeth R
ER
Fintel
Dan J
DJ
Gibler
W Brian
WB
Ohman
E Magnus
EM
Smith
Sidney C
SC
Peterson
Eric D
ED
D000368:Aged; D000369:Aged, 80 and over; D003327:Coronary Disease / Q000628:therapy*; D004562:Electrocardiography; D005260:Female; D019983:Guideline Adherence; D006279:Health Maintenance Organizations / Q000592:standards; D006297:Health Services Accessibility / Q000592:standards*; D006801:Humans; D019458:Insurance Coverage / Q000592:standards*; D007348:Insurance, Health / Q000592:standards; D008297:Male; D008484:Medicaid / Q000592:standards; D006278:Medicare / Q000592:standards; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care; D013577:Syndrome