Should fee-for-service be for all guideline-advocated acute coronary syndrome (ACS) care? Observations from the Snapshot ACS study.
OBJECTIVE
The aim of the present study was to explore the association of health insurance status on the provision of guideline-advocated acute coronary syndrome (ACS) care in Australia.


METHODS
Consecutive hospitalisations of suspected ACS from 14 to 27 May 2012 enrolled in the Snapshot study of Australian and New Zealand patients were evaluated. Descriptive and logistic regression analysis was performed to evaluate the association of patient risk and insurance status with the receipt of care.


RESULTS
In all, 3391 patients with suspected ACS from 247 hospitals (23 private) were enrolled in the present study. One-third of patients declared private insurance coverage; of these, 27.9% (304/1088) presented to private facilities. Compared with public patients, privately insured patients were more likely to undergo in-patient echocardiography and receive early angiography; furthermore, in those with a discharge diagnosis of ACS, there was a higher rate of revascularisation (P < 0.001). Each of these attracts potential fee-for-service. In contrast, proportionately fewer privately insured ACS patients were discharged on selected guideline therapies and were referred to a secondary prevention program (P = 0.056), neither of which directly attracts a fee. Typically, as GRACE (the Global Registry of Acute Coronary Events) risk score rose, so did the level of ACS care; however, propensity-adjusted analyses showed lower in-hospital adverse events among the insured group (odds ratio 0.68; 95% confidence interval 0.52-0.88; P = 0.004).


CONCLUSIONS
Fee-for-service reimbursement may explain differences in the provision of selected guideline-advocated components of ACS care between privately insured and public patients.
University of Western Australia, M431, 35 Stirling Highway, Crawley, WA 6009, Australia.
Thomas G
TG
Briffa
Royal Brisbane and Women's Hospital, Butterfield Terrace, Brisbane, Qld 4029, Australia. Email.
Christopher J
CJ
Hammett
Heart Care Partners, L5, Sandford Jackson Building, 30 Chasely Street, Auchenflower, Qld 4066, Australia. Email.
David B
DB
Cross
St Vincent's Hospital Melbourne, PO Box 2900, Fitzroy, Vic. 3065, Australia. Email.
Andrew I
AI
Macisaac
Royal Perth Hospital, Wellington Street, Perth, WA 6000, Australia. Email.
James M
JM
Rankin
eHealth & Medication Safety, L5, 255 Elizabeth Street, Sydney, NSW 2000, Australia. Email.
Neville
N
Board
Agency for Clinical Innovation (ACI), 67 Albert Street, Sydney, NSW 2057, Australia. Email.
Bridie
B
Carr
The George Institute for Global Health, L10, King George V Building, 83-117 Missenden Road, Camperdown, NSW 2050, Australia. Email.
Karice K
KK
Hyun
Liverpool Hospital, Elizabeth Street, Liverpool, NSW 2170, Australia. Email.
John
J
French
Concord Hospital, Hospital Road, Concord, NSW 2139, Australia. Email.
David B
DB
Brieger
Flinders University and Flinders Medical Centre, Flinders Drive, Bedford Park, 5042, SA, Australia. Email.
Derek P
DP
Chew
D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000628:therapy*; D000368:Aged; D001315:Australia; D018588:Fee-for-Service Plans; D005260:Female; D006760:Hospitalization; D006801:Humans; D019458:Insurance Coverage; D008297:Male; D009520:New Zealand; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012306:Risk