title: Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction.
abstract: BACKGROUND
  Little is known about how health insurance status affects decisions to seek care during emergency medical conditions such as acute myocardial infarction (AMI).
  
  
  OBJECTIVE
  To examine the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during AMI.
  
  
  METHODS
  Multicenter, prospective study using a registry of 3721 AMI patients enrolled between April 11, 2005, and December 31, 2008, at 24 US hospitals. Health insurance status was categorized as insured without financial concerns, insured but have financial concerns about accessing care, and uninsured. Insurance information was determined from medical records while financial concerns among those with health insurance were determined from structured interviews.
  
  
  METHODS
  Prehospital delay times (< or = 2 hours, > 2-6 hours, or > 6 hours), adjusted for demographic, clinical, and social and psychological factors using hierarchical ordinal regression models.
  
  
  RESULTS
  Of 3721 patients, 2294 were insured without financial concerns (61.7%), 689 were insured but had financial concerns about accessing care (18.5%), and 738 were uninsured (19.8%). Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI and had prehospital delays of greater than 6 hours among 48.6% of uninsured patients and 44.6% of insured patients with financial concerns compared with only 39.3% of insured patients without financial concerns. Prehospital delays of less than 2 hours during AMI occurred among 36.6% of those insured without financial concerns compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients (P < .001). After adjusting for potential confounders, prehospital delays were associated with insured patients with financial concerns (adjusted odds ratio, 1.21 [95% confidence interval, 1.05-1.41]; P = .01) and with uninsured patients (adjusted odds ratio, 1.38 [95% confidence interval, 1.17-1.63]; P < .001).
  
  
  CONCLUSIONS
  Lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.
authors.affiliation: Center of Research on Psychology in Somatic Diseases, Department of Medical Psychology and Neuropsychology, Tilburg University, Tilburg, The Netherlands.
authors.forename: Kim G
authors.initials: KG
authors.lastname: Smolderen
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
authors.forename: Fengming
authors.initials: F
authors.lastname: Tang
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Ross
authors.forename: Henry H
authors.initials: HH
authors.lastname: Ting
authors.forename: Karen P
authors.initials: KP
authors.lastname: Alexander
authors.forename: Saif S
authors.initials: SS
authors.lastname: Rathore
authors.forename: Paul S
authors.initials: PS
authors.lastname: Chan
mesh_terms: D000328:Adult; D000368:Aged; D057210:Delayed Diagnosis / Q000191:economics*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D008297:Male; D017057:Medically Uninsured; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis*; D010342:Patient Acceptance of Health Care; D011446:Prospective Studies; D012042:Registries; D013997:Time Factors; D014481:United States
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