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Financial Barriers to Health Care and Outcomes After Acute Myocardial Infarction
Ali R. Rahimi, MD, MPH;
John A. Spertus, MD, MPH;
Kimberly J. Reid, MS;
Susannah M. Bernheim, MD, MHS;
Harlan M. Krumholz, MD, SM
JAMA. 2007;297:1063-1072.
Context The prevalence and consequences of financial barriers to health care services and medications are not well documented for patients with an acute myocardial infarction (AMI).
Objective To measure the baseline prevalence of self-reported financial barriers to health care services or medication (as defined by avoidance due to cost) among individuals following AMI and their association with subsequent health care outcomes.
Design, Setting, and Participants The Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, multicenter US study of patients with AMI over 12 months in 2498 individuals enrolled from January 2003 through June 2004.
Main Outcome Measures Health status symptoms (Seattle Angina Questionnaire [SAQ]), overall health status function (Short Form-12), and rehospitalization.
Results The prevalence of self-reported financial barriers to health care services or medication was 18.1% and 12.9%, respectively. Among individuals who reported financial barriers to health care services or medication, 68.9% and 68.5%, respectively, were insured. At 1-year follow-up, individuals with financial barriers to health care services were more likely to have lower SAQ quality-of-life score (77.9 vs 86.2; adjusted mean difference= –4.0; 95% confidence interval [CI], –6.3 to –1.8), and increased rates of all-cause rehospitalization (49.3% vs 38.1%; adjusted hazard ratio [HR], 1.3; 95% CI, 1.1-1.5) and cardiac rehospitalization (25.7% vs 17.7%; adjusted HR, 1.3; 95% CI, 1.0-1.6). At 1-year follow-up, individuals with financial barriers to medication were more likely to have angina (34.9% vs 17.9%; adjusted odds ratio, 1.55; 95% CI, 1.1-2.2), lower SAQ quality-of-life score (74.0 vs 86.1; adjusted mean difference = –7.6; 95% CI, –10.2 to –4.9), and increased rates of all-cause rehospitalization (57.0% vs 37.8%; risk-adjusted HR, 1.5; 95% CI, 1.2-1.8) and cardiac rehospitalization (33.7% vs 17.3%; adjusted HR, 1.7; 95% CI, 1.3-2.2).
Conclusion Financial barriers to health care services and medications are associated with worse recovery after AMI, manifested as more angina, poorer quality of life, and higher risk of rehospitalization.
Author Affiliations: Department of Medicine (Dr Rahimi), Section of Geriatrics, Department of Medicine (Dr Bernheim), Section of Cardiovascular Medicine, and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, and Section of Health Policy and Administration, Department of Epidemiology and Public Health (Dr Krumholz), Yale University School of Medicine, New Haven, Conn; Department of Cardiology, Mid America Heart Institute of St Luke's Hospital, Kansas City, Mo (Dr Spertus and Ms Reid); Department of Cardiology, University of Missouri—Kansas City (Dr Spertus); and the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn (Dr Krumholz).
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