JAMA: MI care delayed in patients w/o insurance, w/ other financial woes

Patients who do not have healthcare insurance, or those with insurance but other financial concerns about accessing healthcare, are more likely to delay seeking emergency care for a heart attack, according to a study in the April 14 issue of Journal of the American Medical Association.

Although healthcare insurance status has been shown to affect use of preventive screening and chronic care, little is known about how this status affects decisions to seek care during an emergency medical condition, such as an acute MI (AMI), according to the authors. Also, they wrote that studies have not examined whether financial concerns from the patient’s perspective about accessing medical care in those with healthcare insurance is associated with pre-hospital delays.

“Because pre-hospital delays are associated with higher AMI morbidity and mortality, demonstrating that patients with no insurance or those with insurance but reporting financial concerns about accessing care are at higher risk for pre-hospital delays is important because it would suggest that reducing financial barriers to care—perhaps through expansion of benefits or health insurance coverage—could reduce delays and improve outcomes,” the authors wrote.

Kim G. Smolderen, PhD, of Tilburg University in Tilburg, the Netherlands, and colleagues used a registry of 3,721 AMI patients enrolled between April 2005 and December 2008 at 24 U.S. hospitals. They categorized health insurance status as insured without financial con­cerns, insured but with 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. Pre-hospital delay times were categorized as two hours or less, between two to six hours or greater than six hours.

Of the 3,721 patients in the study group, 2,294 were insured without financial concerns (61.7 percent), 689 were insured but had fi­nancial concerns about accessing care (18.5 percent) and 738 were uninsured (19.8 percent), according to the researchers. Among those with insurance re­porting financial concerns, 82.8 percent reported having avoided medical care, 55.6 percent reported having avoided taking medications and 12.8 percent reported having had difficulty obtaining healthcare services due to costs.

Regarding delays in arriving at the hospital, Smolderen and colleagues found a greater proportion (36.6 percent) of insured patients without financial con­cerns arrived within two hours of symp­tom onset compared with 33.5 percent of in­sured patients with financial concerns and 27.5 percent of uninsured patients.

“Con­versely, a smaller proportion (39.3 percent) of insured patients without financial con­cerns arrived more than six hours from symptom onset compared with 44.6 percent of insured patients with financial con­cerns and 48.6 percent of uninsured patients,” the researchers reported. After adjustment for various factors, they found that pre-hospital delays were associated with insured patients with financial concerns and with uninsured patients.

“These findings underscore important consequences from inadequate healthcare insurance cover­age for the substantial number of individu­als in the U.S. experiencing AMIs,” the authors wrote. “The data also suggest that efforts to reduce pre-hospital delay times may have limited impact without first ensuring that access to health insurance is improved and finan­cial concerns are addressed in patients who seek emergency care.”

Smolderen and colleagues added that it is likely that uninsured patients and insured patients with financial con­cerns about accessing care not only de­layed seeking care for AMI, but also de­layed care for other common medical conditions, such as stroke.

“As a result, interventions that broaden and ensure the affordability of health insurance cov­erage in the U.S. may reduce times to presentation for all emergent medical conditions,” the authors concluded.