Health Care Insurance, Financial Concerns in Accessing Care, and Delays to Hospital Presentation in Acute Myocardial Infarction
- Kim G. Smolderen, PhD;
- John A. Spertus, MD, MPH;
- Brahmajee K. Nallamothu, MD, MPH;
- Harlan M. Krumholz, MD, SM;
- Fengming Tang, MS;
- Joseph S. Ross, MD, MHS;
- Henry H. Ting, MD, MBA;
- Karen P. Alexander, MD;
- Saif S. Rathore, MPH;
- Paul S. Chan, MD, MSc
- Author Affiliations: Center of Research on Psychology in Somatic Diseases, Department of Medical Psychology and Neuropsychology, Tilburg University, Tilburg, the Netherlands (Dr Smolderen); Saint Luke's Mid America Heart Institute, Kansas City, Missouri (Drs Spertus and Chan and Ms Tang); Department of Internal Medicine, School of Medicine, University of Missouri, Kansas City (Dr Spertus and Chan); VA Health Services Research and Development Center for Excellence and Department of Medicine, University of Michigan Medical School, Ann Arbor (Dr Nallamothu); Robert Wood Johnson Clinical Scholars Program (Dr Krumholz), MD/PhD Program, Yale University School of Medicine, New Haven, Connecticut (Dr Krumholz and Mr Rathore); Section of Health Policy and Administration, Department of Epidemiology and Public Health, and the Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut (Dr Krumholz); Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York (Dr Ross); HSR&D Research Enhancement Award Program and Geriatrics Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York (Dr Ross); Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota (Dr Ting); and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina (Dr Alexander).
Abstract
Context 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.
Design, Setting, and Patients 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.
Main Outcome Measure Prehospital delay times (≤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).
Conclusion 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.
