Insurance status appears to affect cardiac care

By LEE BOWMAN
Monday, November 20, 2006
Medicaid patients with heart trouble are less likely to get recommended levels of care compared to people with private insurance, researchers have found.

A team led by Dr. James Calvin, director of cardiology at Rush University Medical Center in Chicago evaluated the care of more than 37,000 patients younger than 65 and more than 59,000 elderly patients at 521 hospitals across the country.

All the patients were suffering from acute coronary syndromes, a condition in which there is inadequate blood supply to heart muscles. If the blockage lasts long enough, muscle dies, causing a heart attack.

The researchers studied medical records to determine the extent that treatment of the patients followed guidelines set for their condition by the American College of Cardiology and the American Heart Association. The study ran from January 2001 through March 2005.

The guidelines include starting recommended medications within 24 hours of diagnosis, using drugs and dietary advances to control cholesterol levels, counseling to stop smoking and the use of cardiac rehabilitation programs.

Calvin and colleagues from several other institutions around the country published their findings Tuesday in the Annals of Internal Medicine.

Compared with patients who were in an HMO or private health insurance plan, patients covered by the federal-state program for low-income people were less likely to get aspirin, beta-blockers and other blood-thinning and cholesterol-lowering drugs. There were also longer delays for them to receive a first electrocardiogram and to undergo heart catheterization or bypass surgery when those procedures were ordered.

Medicaid patients had higher in-hospital mortality rates (2.9 percent versus 1.2 percent) and, after adjustment for other health factors, the risk for death was about 30 percent higher for Medicaid patients than others covered by private insurance.

Differences in level of care and in mortality rates were much smaller for the older patients eligible for Medicare, regardless of whether they were "dual-eligibles" for Medicaid coverage.

"It is reassuring to find that the Medicare system for our older Americans appears to be working, but disappointing to find insurance status affects quality of care and clinical outcomes for cardiac patients under the age of 65," Calvin said.

The researchers say it's not clear why there is so much difference in what's done for the patients with different types of coverage, but noted the root is not likely to be that Medicaid patients are poor and that their care may not be as generously reimbursed.

"On the surface, people may conclude that doctors have a bias against poor people. However, it doesn't cost a thing to tell someone to watch the salt in their diet or to quit smoking, which is really good advice to reduce heart problems," Calvin said. Yet they are done less consistently for Medicaid patients.

"We need further study to determine if system problems, such as lack of computerized record-keeping or not enough nurses, contribute to this disparity. Care by non-cardiologists may also be partly responsible."

On the Net: www.annals.org