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NSTEACS Care by Insurance Type

Among NSTEACS patients younger than 65, Medicaid insurance was associated with less frequent delivery of guideline-recommended care and with higher short-term mortality, compared with non-Medicaid insurance.

Does the care given after non–ST-segment-elevation acute coronary syndrome (NSTEACS) events vary by the type of insurance used? Researchers affiliated with the CRUSADE quality-improvement initiative analyzed treatment and outcomes data from patients who each received care for an NSTEACS event at one of 521 U.S. hospitals. Of 37,345 patients younger than 65, 19% were covered by Medicaid and the rest by HMOs or private insurance; of 59,550 patients age 65 or older, 68% were covered by Medicare and the rest by HMOs or private insurance. African Americans made up 26% of the Medicaid group and less than 10% of the other insurance groups.

In the younger cohort, Medicaid patients were significantly less likely than patients with HMO or private insurance to receive most guideline-recommended medications during the first 24 hours after presentation and at discharge, and to undergo invasive cardiac procedures. (Patients with contraindications to treatments were not counted.) Medicaid patients also had significantly higher unadjusted rates of in-hospital adverse outcomes than their HMO-insured and privately insured counterparts; only the higher risk for death persisted in an adjusted analysis that included hospital characteristics (odds ratio, 1.33; 95% CI, 1.08–1.63).

In the older cohort, Medicare patients and their HMO-insured and privately insured counterparts had similar rates of receiving guideline-recommended medications within the first 24 hours and at discharge, and of undergoing invasive cardiac procedures. No association was found between insurance type and in-hospital adverse outcomes, including death, in this older cohort.

Comment: The obvious goal for clinical practice is to deliver guideline-recommended care to NSTEACS patients regardless of their insurance type. These data show that Medicaid patients younger than age 65 have lower rates of receiving such care and higher short-term mortality rates than their counterparts with HMO or private insurance. Further research will need to address why these differences exist, as the present study did not account for coexisting medical conditions or determine the appropriateness of use of invasive cardiac procedures.

— Joel M. Gore, MD

Published in Journal Watch Cardiology November 20, 2006

Citation(s):

Calvin JE et al. Insurance coverage and care of patients with non-ST-segment elevation acute coronary syndromes. Ann Intern Med 2006 Nov 21; 145:739-48.

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