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Malhotra AK, Shakil H, Essa A, Mathieu F, Taran S, Badhiwala J, He Y, Yuan EY, Kulkarni AV, Wilson JR, Nathens AB, Witiw CD. Influence of health insurance on withdrawal of life sustaining treatment for patients with isolated traumatic brain injury: a retrospective multi-center observational cohort study. Crit Care 2024; 28:251. [PMID: 39026325 PMCID: PMC11264615 DOI: 10.1186/s13054-024-05027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/06/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Healthcare inequities for patients with traumatic brain injury (TBI) represent a major priority area for trauma quality improvement. We hypothesized a relationship between health insurance status and timing of withdrawal of life sustaining treatment (WLST) for adults with severe TBI. METHODS This multicenter retrospective observational cohort study utilized data collected between 2017 and 2020. We identified adult (age ≥ 16) patients with isolated severe TBI admitted participating Trauma Quality Improvement Program centers. We determined the relationship between insurance status (public, private, and uninsured) and the timing of WLST using a competing risk survival analysis framework adjusting for baseline, clinical, injury and trauma center characteristics. Multivariable cause-specific Cox regressions were used to compute adjusted hazard ratios (HR) reflecting timing of WLST, accounting for mortality events. We also quantified the between-center residual variability in WLST using the median odds ratio (MOR) and measured insurance status association with access to rehabilitation at discharge. RESULTS We identified 42,111 adults with isolated severe TBI treated across 509 trauma centers across North America. There were 10,771 (25.6%) WLST events in the cohort and a higher unadjusted incidence of WLST events was evident in public insurance patients compared to private or uninsured groups. After adjustment, WLST occurred earlier for publicly insured (HR 1.07, 95% CI 1.02-1.12) and uninsured patients (HR 1.29, 95% CI 1.18-1.41) compared to privately insured patients. Access to rehabilitation was lower for both publicly insured and uninsured patients compared to patients with private insurance. Accounting for case-mix, the MOR was 1.49 (95% CI 1.43-1.55), reflecting significant residual between-center variation in WLST decision-making. CONCLUSIONS Our findings highlight the presence of disparate WLST practices independently associated with health insurance status. Additionally, these results emphasize between-center variability in WLST, persisting despite adjustments for measurable patient and trauma center characteristics.
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Affiliation(s)
- Armaan K Malhotra
- Division of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Husain Shakil
- Division of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ahmad Essa
- Division of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
- Division of Orthopedics, Department of Surgery, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Francois Mathieu
- Division of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Shaurya Taran
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jetan Badhiwala
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Yingshi He
- Division of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Eva Y Yuan
- Division of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Abhaya V Kulkarni
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Avery B Nathens
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada.
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 182] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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de Oliveira Costa J, Pearson SA, Brieger D, Lujic S, Shawon MSR, Jorm LR, van Gool K, Falster MO. In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals. Int J Equity Health 2023; 22:226. [PMID: 37872627 PMCID: PMC10594777 DOI: 10.1186/s12939-023-02030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND International evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). METHODS We conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017-2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors. RESULTS Of 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45-0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients. CONCLUSION Our findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.
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Affiliation(s)
- Juliana de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia.
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia.
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - David Brieger
- Concord Clinical School - The University of Sydney, Sydney, Australia
| | - Sanja Lujic
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Md Shajedur Rahman Shawon
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Kees van Gool
- Centre for Health Economics Research and Evaluation - University of Technology Sydney, Sydney, Australia
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1460] [Impact Index Per Article: 1460.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Moverman MA, Sudah SY, Puzzitiello RN, Pagani NR, Hart PA, Swanson D, Kirsch JM, Jawa A, Menendez ME. Neighborhood socioeconomic disadvantage does not predict outcomes or cost after elective shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:2465-2472. [PMID: 35671927 DOI: 10.1016/j.jse.2022.04.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/17/2022] [Accepted: 04/24/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is growing evidence that the variation in value of shoulder arthroplasty may be mediated by factors external to surgery. We sought to determine if neighborhood-level socioeconomic deprivation is associated with postoperative outcomes and cost among patients undergoing elective shoulder arthroplasty. METHODS We identified 380 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Each patient's home address was mapped to the area deprivation index in order to determine the level of socioeconomic disadvantage. The area deprivation index is a validated composite measure of 17 census variables encompassing income, education, employment, and housing conditions. Patients were categorized into 3 groups based on socioeconomic disadvantage (least disadvantaged [deciles 1-3], middle group [4-6], and most disadvantaged [7-10]). Bivariate analysis was performed to determine associations between the level of socioeconomic deprivation with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and pain intensity scores. RESULTS Overall 19% of patients were categorized as most disadvantaged. These patients were found to have equivalent preoperative pain intensity (P = .51), SANE (P = .50), and ASES (P = .72) scores compared to the middle and least disadvantaged groups, as well as similar outcome improvement at 2 years postoperatively (ASES): least disadvantaged group [35.7-84.3], middle group [35.1-82.4], and most disadvantaged group [37.1-84.0] [P = .56]; SANE: least disadvantaged group [31.8-87.1], middle group [30.8-84.8], and most disadvantaged group [34.2-85.1] [P = .42]; and pain: least disadvantaged group [6.0-0.97], middle group [6-0.97], and most disadvantaged group [5.6-0.80] [P = .88]. No differences in hospitalization costs were noted between groups (P = .77). CONCLUSIONS Patients undergoing elective shoulder arthroplasty residing in the most disadvantaged neighborhoods demonstrate equivalent preoperative and postoperative outcomes as others, without incurring higher costs. These findings support continued efforts to provide equitable access to orthopedic care across the socioeconomic spectrum.
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Affiliation(s)
- Michael A Moverman
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA.
| | - Suleiman Y Sudah
- Department of Orthopedics, Monmouth Medical Center, Long Branch, NJ, USA
| | - Richard N Puzzitiello
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA
| | - Nicholas R Pagani
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA
| | - Paul A Hart
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Daniel Swanson
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Jacob M Kirsch
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Andrew Jawa
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Mariano E Menendez
- Midwest Orthopaedics at Rush, Rush University, Chicago, IL, USA; Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, OR, USA
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Gupta R, Makkar JS, Sharma SK, Agarwal A, Sharma KK, Bana A, Kasliwal A, Sidana SK, Degawat PR, Bhagat KK, Natani V, Khedar RS, Sharma SK. Association of health insurance status with coronary risk factors, coronary artery disease, interventions and outcomes in India. INTERNATIONAL JOURNAL OF CARDIOLOGY CARDIOVASCULAR RISK AND PREVENTION 2022; 14:200146. [PMID: 36060285 PMCID: PMC9434410 DOI: 10.1016/j.ijcrp.2022.200146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/14/2022] [Accepted: 07/23/2022] [Indexed: 11/30/2022]
Abstract
Objective Coronary artery disease (CAD) related hospitalization and interventions are associated with catastrophic out-of-pocket health expenditure in India. To evaluate differences in risk factors, disease severity, management and outcomes in uninsured vs insured CAD patients we performed a study. Methods Successive CAD patients who underwent percutaneous intervention (PCI) at our centre were enrolled from January 2018 to June 2021. Clinical, angiographic and intervention data were periodically uploaded in the American College of Cardiology CathPCI platform. Descriptive statistics are reported. Results 4672 CAD patients (men 3736, women 936) were included; uninsured were 2166 (46%), government insurance was in 1635 (36%) and private insurance in 871 (18%). Mean age was 60.1 ± 11 years, uninsured <50y were 21.6% vs 14.0% and 20.3% with government and private insurance. Among the uninsured prevalence of raised total and non-HDL cholesterol, any tobacco use, ST-elevation myocardial infarction (STEMI) and ejection fraction <30% were more (p < 0.01). In the STEMI group (n = 1985), rates of primary PCI were the highest in those with private insurance (38.7%) compared to others. Multivessel stenting (≥2 stents) was more among the insured patients. Median length of hospital stay was similar in the three groups. In-hospital mortality was slightly more in the uninsured (1.43%), compared to government (0.88) and privately insured (0.82) (p = 0.242). The cost of hospitalization and procedures was the highest among uninsured (US$ 2240, IQR 1877–2783) compared to government (US$ 1977, IQR 1653–2437) and privately insured (US$ 2013, IQR 1668–2633) (p < 0.001). Conclusions Uninsured CAD patients in India are younger with more risk factors, acute coronary syndrome, STEMI, multivessel disease and coronary stenting compared to those with government or private insurance. The uninsured bear significantly greater direct costs with slightly greater mortality.
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Socioeconomic inequity in incidence, outcomes and care for acute coronary syndrome: A systematic review. Int J Cardiol 2022; 356:19-29. [DOI: 10.1016/j.ijcard.2022.03.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 02/17/2022] [Accepted: 03/24/2022] [Indexed: 12/17/2022]
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Vallabhajosyula S, Kumar V, Sundaragiri PR, Cheungpasitporn W, Miller PE, Patlolla SH, Gersh BJ, Lerman A, Jaffe AS, Shah ND, Holmes DR, Bell MR, Barsness GW. Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared With Privately Insured Individuals. Circ Heart Fail 2022; 15:e008991. [PMID: 35240866 PMCID: PMC9930186 DOI: 10.1161/circheartfailure.121.008991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. METHODS Using the National Inpatient Sample (2000-2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer-self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. RESULTS Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P<0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13-1.17]; P<0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83-0.87]; P<0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P<0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55-1.68]; P<0.001) and resource utilization. CONCLUSIONS Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Vinayak Kumar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, North Carolina
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - P Elliott Miller
- Division of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota,Department of Health Services Research, Mayo Clinic, Rochester, Minnesota
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Steen DL, Khan I, Andrade K, Koumas A, Giugliano RP. Event Rates and Risk Factors for Recurrent Cardiovascular Events and Mortality in a Contemporary Post Acute Coronary Syndrome Population Representing 239 234 Patients During 2005 to 2018 in the United States. J Am Heart Assoc 2022; 11:e022198. [PMID: 35475346 PMCID: PMC9238606 DOI: 10.1161/jaha.121.022198] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Patients with acute coronary syndrome (ACS) are recognized by guidelines as remaining at high risk for adverse outcomes. Evidence from contemporary, representative ACS populations in a clinical practice setting is necessary to identify subgroups and strategies for improving patient outcomes. We aimed to describe event rates and risk factors in an ACS population over prolonged follow‐up for cardiovascular end points. Methods and Results We identified 239 234 patients in the Optum Research Database (57.2% men; mean [standard deviation] age, 69.2 [12.2] years) with evidence of an ACS hospitalization (index ACS) during January 1, 2005 through December 30, 2018. Subgroups were based on index ACS event (myocardial infarction/unstable angina and revascularization status) and the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention. The 5‐year event rate for the primary end point representing nonfatal myocardial infarction, nonfatal ischemic stroke, and cardiovascular death was 33.4% (95% CI, 33.1%–33.7%; P<0.001). The risk of experiencing the primary end point was ≈6‐fold higher immediately after discharge (≈40.9% annualized risk) as compared with the period 1+ years after hospitalization (≈6.4% annualized risk). Among subgroups, the 5‐year primary end point event rate was highest for myocardial infarction without revascularization and a Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention ≥4, at 47.9% (95% CI, 47.3%–48.4%; P<0.001) and 56.7% (95% CI, 55.9%–57.4%; P<0.001), respectively. Conclusions Patients with ACS remain at very high risk of experiencing recurrent cardiovascular events, particularly early after discharge, with identifiable subgroups at multifold higher risk of specific clinical end points.
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Affiliation(s)
- Dylan L Steen
- Division of Cardiovascular Health and Disease Department of Medicine University of Cincinnati OH
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Tizón-Marcos H, Vaquerizo B, Ferré JM, Farré N, Lidón RM, Garcia-Picart J, Regueiro A, Ariza A, Carrillo X, Duran X, Poirier P, Cladellas M, Camps-Vilaró A, Ribas N, Cubero-Gallego H, Marrugat J. Socioeconomic Status and Prognosis of Patients With ST-Elevation Myocardial Infarction Managed by the Emergency-Intervention “Codi IAM” Network. Front Cardiovasc Med 2022; 9:847982. [PMID: 35548422 PMCID: PMC9082814 DOI: 10.3389/fcvm.2022.847982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDespite the spread of ST-elevation myocardial infarction (STEMI) emergency intervention networks, inequalities in healthcare access still have a negative impact on cardiovascular prognosis. The Family Income Ratio of Barcelona (FIRB) is a socioeconomic status (SES) indicator that is annually calculated. Our aim was to evaluate whether SES had an effect on mortality and complications in patients managed by the “Codi IAM” network in Barcelona.MethodsThis is a cohort study with 3,322 consecutive patients with STEMI treated in Barcelona from 2010 to 2016. Collected data include treatment delays, clinical and risk factor characteristics, and SES. The patients were assigned to three SES groups according to FIRB score. A logistic regression analysis was conducted to estimate the adjusted effect of SES on 30-day mortality, 30-day composite cardiovascular end point, and 1-year mortality.ResultsThe mean age of the patients was 65 ± 13% years, 25% were women, and 21% had diabetes mellitus. Patients with low SES were younger, more often hypertensive, diabetic, dyslipidemic (p < 0.003), had longer reperfusion delays (p < 0.03) compared to participants with higher SES. Low SES was not independently associated with 30-day mortality (OR: 0.95;9 5% CI: 0.7–1.3), 30-day cardiovascular composite end point (OR: 1.03; 95% CI: 0.84–1.26), or 1-year all-cause mortality (HR: 1.09; 95% CI: 0.76–1.56).ConclusionAlthough the low-SES patients with STEMI in Barcelona city were younger, had worse clinical profiles, and had longer revascularization delays, their 30-day and 1-year outcomes were comparable to those of the higher-SES patients.
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Affiliation(s)
- Helena Tizón-Marcos
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- *Correspondence: Helena Tizón-Marcos
| | - Beatriz Vaquerizo
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Josepa Mauri Ferré
- Hospital Universitari GermansTrias I. Pujol, Servicio de Cardiología, Badalona, Spain
- Departament de Salut, Generalitat de Catalunya, Barcelona, Spain
| | - Núria Farré
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Rosa-Maria Lidón
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Hospital Universitari de la Valld'Hebron, Servicio de Cardiología, Barcelona, Spain
| | - Joan Garcia-Picart
- Hospital de la Santa Creu I. Sant Pau, Servicio de Cardiología, Barcelona, Spain
| | - Ander Regueiro
- Hospital Clínic i Provincial, Servicio de Cardiología, Barcelona, Spain
| | - Albert Ariza
- Hospital Universitario de Bellvitge, Servicio de Cardiología, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Carrillo
- Hospital Universitari GermansTrias I. Pujol, Servicio de Cardiología, Badalona, Spain
| | - Xavier Duran
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- AMIB, Assessoria Metodològica i Bioestadística, Barcelona, Spain
| | - Paul Poirier
- Insititut Universitaire de Cardiologie et Pneumologie de Québec, Québec, QC, Canada
| | - Mercè Cladellas
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Anna Camps-Vilaró
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Núria Ribas
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Hector Cubero-Gallego
- Hospital del Mar, Servicio de Cardiología, Barcelona, Spain
- Grupo de Investigación Biomédica en Enfermedades del Corazón, Barcelona, Spain
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
| | - Jaume Marrugat
- IMIM (Instituto Hospital del Mar de Investigaciones Médicas), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2629] [Impact Index Per Article: 1314.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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12
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Buckman M, Grant A, Henson S, Ribeiro J, Roth K, Stranton D, Korvink M, Gunn LH. A review of socioeconomic factors associated with acute myocardial infarction-related mortality and hospital readmissions. Hosp Pract (1995) 2022; 50:1-8. [PMID: 34933647 DOI: 10.1080/21548331.2021.2022357] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Risk-adjustment models are widely used methodological approaches within the healthcare industry to measure hospital performance and quality of care. However, the Centers for Medicare and Medicaid Services (CMS) do not fully adjust for socioeconomic status (SES) in acute myocardial infarction (AMI) models. A review and evidence synthesis was conducted to identify associations of SES factors with hospital readmission and mortality in AMI patients. METHODS Multiple electronic databases were queried to identify studies assessing risk for AMI-related mortality or hospital readmissions and SES factors. Identified studies were screened by title and abstract. Full-text reviews followed for articles meeting the inclusion criteria, including quality assessments. Data were extracted from all included studies, and evidence synthesis was performed to identify associations between SES factors and outcome variables. RESULTS Ten studies were included in the review. One study showed that Black patients had higher AMI-related readmission rates compared to White patients (mean difference 4.3% [SD 1.4%], p < 0.001). Another study showed that income inequality was associated with increased risk of AMI-related readmissions (RR 1.18 [95% CI], 1.13-1.23). One study found that unemployed individuals experienced significantly greater rates of AMI-related mortality than those working full-time (HR 2.08, 1.51-2.87). According to another study, lack of health insurance was associated with worse rates for in-hospital AMI-related mortality (OR 1.77, 1.72-1.82). Based on one study, AMI-related mortality was higher in those with <8 years of education compared to those with >16 years (17.5% vs. 3.5%, p < 0.0001). Five of six studies found a significant association between ZIP code/neighborhood/location and AMI-related readmission or mortality. CONCLUSION Race, ZIP code/neighborhood/location, insurance status, income/poverty, and education comprise SES factors found to be associated with AMI-related mortality and/or readmission outcomes. Including these SES factors in future updates of CMS's risk-adjusted models has the potential to provide more appropriate compensation mechanisms to hospitals.
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Affiliation(s)
- Mercy Buckman
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA.,School of Data Science, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Amanda Grant
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA.,School of Data Science, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Sally Henson
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA.,School of Data Science, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Julia Ribeiro
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA.,School of Data Science, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Katie Roth
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA.,School of Data Science, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Derek Stranton
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA.,School of Data Science, University of North Carolina at Charlotte, Charlotte, NC, USA
| | | | - Laura H Gunn
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA.,School of Data Science, University of North Carolina at Charlotte, Charlotte, NC, USA.,Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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13
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Daley S, Kajendrakumar B, Nandhakumar S, Personett C, Sholes M, Thapa S, Xue C, Korvink M, Gunn LH. County-Level Socioeconomic Status Adjustment of Acute Myocardial Infarction Mortality Hospital Performance Measure in the U.S. Healthcare (Basel) 2021; 9:healthcare9111424. [PMID: 34828471 PMCID: PMC8620965 DOI: 10.3390/healthcare9111424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/01/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
The U.S. Centers for Medicare and Medicaid Services’ (CMS’s) Hospital Compare (HC) data provides a collection of risk-adjusted hospital performance metrics intended to allow comparison of hospital-provided care. However, CMS does not adjust for socioeconomic status (SES) factors, which have been found to be associated with disparate health outcomes. Associations between county-level SES factors and CMS’s risk-adjusted 30-day acute myocardial infarction (AMI) mortality rates are explored for n = 2462 hospitals using a variety of sources for county-level SES information. Upon performing multiple imputation, a stepwise backward elimination model selection approach using Akaike’s information criteria was used to identify the optimal model. The resulting model, comprised of 14 predictors mostly at the county level, provides an additional 8% explanatory power to capture the variability in 30-day risk-standardized AMI mortality rates, which already account for patient-level clinical differences. SES factors may be an important feature for inclusion in future risk-adjustment models, which will have system and policy implications for distributing resources to hospitals, such as reimbursements. It also serves as a stepping stone to identify and address long-standing SES-related inequities.
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Affiliation(s)
- Sean Daley
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (S.D.); (B.K.); (S.N.); (C.P.); (M.S.); (S.T.); (C.X.)
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA
| | - Bakthameera Kajendrakumar
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (S.D.); (B.K.); (S.N.); (C.P.); (M.S.); (S.T.); (C.X.)
| | - Samyuktha Nandhakumar
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (S.D.); (B.K.); (S.N.); (C.P.); (M.S.); (S.T.); (C.X.)
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA
| | - Christine Personett
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (S.D.); (B.K.); (S.N.); (C.P.); (M.S.); (S.T.); (C.X.)
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA
| | - Michael Sholes
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (S.D.); (B.K.); (S.N.); (C.P.); (M.S.); (S.T.); (C.X.)
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA
| | - Swornim Thapa
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (S.D.); (B.K.); (S.N.); (C.P.); (M.S.); (S.T.); (C.X.)
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA
| | - Chen Xue
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (S.D.); (B.K.); (S.N.); (C.P.); (M.S.); (S.T.); (C.X.)
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA
| | | | - Laura H. Gunn
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC 28223, USA; (S.D.); (B.K.); (S.N.); (C.P.); (M.S.); (S.T.); (C.X.)
- School of Data Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA
- Faculty of Medicine, School of Public Health, Imperial College London, London W6 8RP, UK
- Correspondence:
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14
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Vallabhajosyula S, Desai VK, Sundaragiri PR, Cheungpasitporn W, Doshi R, Singh V, Jaffe AS, Lerman A, Barsness GW. Influence of primary payer status on non-ST-segment elevation myocardial infarction: 18-year retrospective cohort national temporal trends, management and outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1075. [PMID: 34422987 PMCID: PMC8339860 DOI: 10.21037/atm-20-5193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 01/22/2021] [Indexed: 12/25/2022]
Abstract
Background The role of insurance on outcomes in non-ST-segment-elevation myocardial infarction (NSTEMI) patients is limited in the contemporary era. Methods From the National Inpatient Sample, adult NSTEMI admissions were identified [2000–2017]. Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes included in-hospital mortality, overall and early coronary angiography, percutaneous coronary intervention (PCI), resource utilization and discharge disposition. Results Of the 7,290,565 NSTEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 62.9%, 6.1%, 24.1%, 4.6% and 2.3%, respectively. Compared to others, those with Medicare insurance older (76 vs. 53–60 years), more likely to be female (48% vs. 25–44%), of white race, and with higher comorbidity (all P<0.001). Population from the Medicare cohort had higher in-hospital mortality (5.6%) compared to the others (1.9–3.4%), P<0.001. With Medicare as referent, in-hospital mortality was higher in other {adjusted odds ratio (aOR) 1.15 [95% confidence interval (CI), 1.11–1.19]; P<0.001}, and lower in Medicaid [aOR 0.95 (95% CI, 0.92–0.97); P<0.001], private [aOR 0.77 (95% CI, 0.75–0.78); P<0.001] and uninsured cohorts [aOR 0.97 (95% CI, 0.94–1.00); P=0.06] in a multivariable analysis. Coronary angiography (overall 52% vs. 65–74%; early 15% vs. 22–27%) and PCI (27% vs. 35–44%) were used lesser in the Medicare population. The Medicare population had longer lengths of stay, lowest hospitalization costs and fewer home discharges. Conclusions Compared to other types of primary payers, NSTEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA.,Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Viral K Desai
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Pranathi R Sundaragiri
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA
| | - Rajkumar Doshi
- Department of Medicine, University of Nevada Reno School of Medicine, Reno, Nevada, USA
| | - Vikas Singh
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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Lee SJ, Han KS, Lee EJ, Lee SW, Ki M, Ahn HS, Kim SJ. Impact of insurance type on outcomes in cardiac arrest patients from 2004 to 2015: A nation-wide population-based study. PLoS One 2021; 16:e0254622. [PMID: 34260639 PMCID: PMC8279316 DOI: 10.1371/journal.pone.0254622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/29/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES There do not appear to be many studies which have examined the socio-economic burden and medical factors influencing the mortality and hospital costs incurred by patients with cardiac arrest in South Korea. We analyzed the differences in characteristics, medical factors, mortality, and costs between patients with national health insurance and those on a medical aid program. METHODS We selected patients (≥20 years old) who experienced their first episode of cardiac arrest from 2004 to 2015 using data from the National Health Insurance Service database. We analyzed demographic characteristics, insurance type, urbanization of residential area, comorbidities, treatments, hospital costs, and mortality within 30 days and one year for each group. A multiple regression analysis was used to identify an association between insurance type and outcomes. RESULTS Among the 487,442 patients with cardiac arrest, the medical aid group (13.3% of the total) had a higher proportion of females, rural residents, and patients treated in low-level hospitals. The patients in the medical aid group also reported a higher rate of non-shockable conditions; a high Charlson Comorbidity Index; and pre-existing comorbidities, such as hypertension, diabetes mellitus, and renal failure with a lower rate of providing a coronary angiography. The national health insurance group reported a lower one-year mortality rate (91.2%), compared to the medical aid group (94%), and a negative association with one-year mortality (Adjusted OR 0.74, 95% CI 0.71-0.76). While there was no significant difference in short-term costs between the two groups, the medical aid group reported lower long-term costs, despite a higher rate of readmission. CONCLUSIONS Medical aid coverage was an associated factor for one-year mortality, and may be the result of an insufficient delivery of long-term services as reflected by the lower long-term costs and higher readmission rates. There were differences of characteristics, comorbidities, medical and hospital factors and treatments in two groups. These differences in medical and hospital factors may display discrepancies by type of insurance in the delivery of services, especially in chronic healthcare services.
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Affiliation(s)
- Si Jin Lee
- Department of Emergency Medicine, College of Medicine, Korea University Hospital, Seoul, South Korea
| | - Kap Su Han
- Department of Emergency Medicine, College of Medicine, Korea University Hospital, Seoul, South Korea
| | - Eui Jung Lee
- Department of Emergency Medicine, College of Medicine, Korea University Hospital, Seoul, South Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, College of Medicine, Korea University Hospital, Seoul, South Korea
| | - Myung Ki
- Department of Preventive Medicine, College of Medicine, Korea University Hospital, Seoul, South Korea
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, College of Medicine, Korea University, Seoul, South Korea
| | - Su Jin Kim
- Department of Emergency Medicine, College of Medicine, Korea University Hospital, Seoul, South Korea
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16
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Shi T, Jiang C, Zhu C, Wu F, Fotjhadi I, Zarich S. Insurance disparity in cardiovascular mortality among non-elderly cancer survivors. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2021; 7:11. [PMID: 33743837 PMCID: PMC7980587 DOI: 10.1186/s40959-021-00098-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/02/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Insurance status plays a vital role in cancer diagnosis, treatments and survival. Cancer patients have higher cardiovascular disease (CVD) mortality than the general population. METHODS The Surveillance, Epidemiology and End Results (SEER) program 2007-2016 was used to estimate the CVD mortality among cancer patients aged 18 to 64 years at the time of diagnosis of an initial malignancy with the eight most prevalent cancers. Standardized mortality ratios (SMRs) were calculated for each insurance (Non-Medicaid vs Medicaid vs Uninsured) using coded cause of death from CVD with adjustment of age, race, and gender. The Fine-Grey Model was used to estimate adjusted Hazard Ratios (HR) of each insurance in CVD mortality. RESULTS A total of 768,055 patients were included in the final analysis. CVD death in patients with Medicaid insurance remained higher than in those with Non-Medicaid insurance (HR = 1.71; 95%CI, 1.61-1.81; p < 0.001). Older age, male gender, and black race were all associated with increased CVD mortality in the multivariable model. Compared to the general population, patients with Medicaid had the highest SMRs of CVD mortality, regardless of year of cancer diagnosis, follow-up time, cancer site, and race. Non-Medicaid insured patients had similar CVD mortality to the general population after 2 years out from their cancer diagnosis. CONCLUSION Cancer patients with Non-Medicaid insurance have significantly lower CVD mortality than those with no insurance or Medicaid. The insurance disparity remained significant regardless of type of CVD, cancer site, year of diagnosis and follow-up time.
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Affiliation(s)
- Tiantian Shi
- Department of Medicine, Bridgeport Hospital, Bridgeport, CT, USA
| | - Changchuan Jiang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Cenjing Zhu
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, USA
| | - Fangcheng Wu
- Department of Medicine, Memorial Hospital West, Pembroke Pines, FL, USA
| | - Irma Fotjhadi
- Division of Cardiovascular Medicine, Bridgeport Hospital, 267 Grant St, Bridgeport, CT, 00610, USA
| | - Stuart Zarich
- Division of Cardiovascular Medicine, Bridgeport Hospital, 267 Grant St, Bridgeport, CT, 00610, USA.
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17
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Pancholy SB, Patel GA, Patel DD, Patel N, Pancholy SA, Patel P, Thomas-Hemak L, Patel TM, Callans DJ. Association between insurance status and in-hospital outcomes in patients with out-of-hospital ventricular fibrillation arrest. Clin Cardiol 2021; 44:511-517. [PMID: 33660870 PMCID: PMC8027577 DOI: 10.1002/clc.23564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/01/2020] [Indexed: 11/12/2022] Open
Abstract
Background Lack of health insurance is associated with adverse clinical outcomes; however, the association between health insurance status and in‐hospital outcomes after out‐of‐hospital ventricular fibrillation (OHVFA) arrest is unclear. Hypothesis Lack of health insurance is associated with worse in‐hospital outcomes after out‐of‐hospital ventricular fibrillation arrest. Methods From January 2003 to December 2014, hospitalizations with a primary diagnosis of OHVFA in patients ≥18 years of age were extracted from the Nationwide Inpatient Sample. Patients were categorized into insured and uninsured groups based on their documented health insurance status. Study outcome measures were in‐hospital mortality, utilization of implantable cardioverter defibrillator (ICD), and cost of hospitalization. Inverse probability weighting adjusted binary logistic regression was performed to identify independent predictors of in‐hospital mortality and ICD utilization and linear regression was performed to identify independent predictors of cost of hospitalization. Results Of 188 946 patients included in the final analyses, 178 005 (94.2%) patients were insured and 10 941 (5.8%) patients were uninsured. Unadjusted in‐hospital mortality was higher (61.7% vs. 54.7%, p < .001) and ICD utilization was lower (15.3% vs. 18.3%, p < .001) in the uninsured patients. Lack of health insurance was independently associated with higher in‐hospital mortality (O.R = 1.53, 95% C.I. [1.46–1.61]; p < .001) and lower utilization of ICD (O.R = 0.84, 95% C.I [0.79–0.90], p < .001). Cost of hospitalization was significantly higher in uninsured patients (median [interquartile range], p‐value) ($) (39 650 [18 034‐93 399] vs. 35 965 [14 568.50‐96 163], p < .001). Conclusion Lack of health insurance is associated with higher in‐hospital mortality, lower utilization of ICD and higher cost of hospitalization after OHVFA.
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Affiliation(s)
- Samir B Pancholy
- Division of Cardiology, Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Gaurav A Patel
- Division of Cardiology, Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Dhara D Patel
- Division of Cardiology, Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Neil Patel
- Division of Cardiology, Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Shivam A Pancholy
- Division of Cardiology, Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Purveshkumar Patel
- Division of Cardiology, Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Linda Thomas-Hemak
- Division of Cardiology, Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Tejas M Patel
- Department of Cardiology, Apex Heart Institute, Ahmedabad, India
| | - David J Callans
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 3176] [Impact Index Per Article: 1058.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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19
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Vallabhajosyula S, Kumar V, Sundaragiri PR, Cheungpasitporn W, Bell MR, Singh M, Jaffe AS, Barsness GW. Influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction in the United States. PLoS One 2020; 15:e0243810. [PMID: 33338071 PMCID: PMC7748387 DOI: 10.1371/journal.pone.0243810] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/26/2020] [Indexed: 12/27/2022] Open
Abstract
Background There are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI). Objective To assess the influence of insurance status on STEMI outcomes. Methods Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample database (2000–2017). Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes of interest included in-hospital mortality, use of coronary angiography and percutaneous coronary intervention (PCI), hospitalization costs, hospital length of stay and discharge disposition. Results Of the 4,310,703 STEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively. Compared to the others, the Medicare cohort was older (75 vs. 53–57 years), more often female (46% vs. 20–36%), of white race, and with higher comorbidity (all p<0.001). The Medicare and Medicaid population had higher rates of cardiogenic shock and cardiac arrest. The Medicare cohort had higher in-hospital mortality (14.2%) compared to the other groups (4.1–6.7%), p<0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in uninsured (adjusted odds ratio (aOR) 1.14 [95% confidence interval {CI} 1.11–1.16]), and lower in Medicaid (aOR 0.96 [95% CI 0.94–0.99]; p = 0.002), privately insured (aOR 0.73 [95% CI 0.72–0.75]) and other insurance (aOR 0.91 [95% CI 0.88–0.94]); all p<0.001. Coronary angiography (60% vs. 77–82%) and PCI (45% vs. 63–70%) were used less frequently in the Medicare population compared to others. The Medicare and Medicaid populations had longer lengths of hospital stay, and the Medicare population had the lowest hospitalization costs and fewer discharges to home. Conclusions Compared to other types of primary payers, STEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, United States of America
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- * E-mail:
| | - Vinayak Kumar
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Pranathi R. Sundaragiri
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, United States of America
| | - Malcolm R. Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Allan S. Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Gregory W. Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
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20
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Ghare MI, Tirziu D, Abbott JD, Altin E, Yang Y, Ng V, Grines C, Lansky A. Sex-Specific Outcomes in Cardiovascular Device Evaluations. J Womens Health (Larchmt) 2020; 29:1246-1255. [PMID: 32543268 DOI: 10.1089/jwh.2019.8068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Females have historically been underrepresented in cardiovascular device trials. As a result, differences in outcomes for males and females are not possible to be determined in subanalyses. Materials and Methods: Against a backdrop of troubling trends in cardiovascular outcomes for females, we provide a narrative review on the differences in outcomes observed in females undergoing device evaluations in multiple fields of cardiovascular medicine, including coronary revascularization, structural heart disease, and heart failure. We also review predictors of cardiovascular trial nonparticipation as it may provide avenues by which female enrollment in cardiovascular device trials can be improved. Results: Advances have been made in structural heart therapy, where female representation in transcatheter aortic valve replacement studies was nearly 50%. For other indications, coronary revascularization and heart failure, there was clearly a disparity in female recruitment. On average, female representation was 25% in major clinical trials evaluating drug eluting stents, implantable cardioverter defibrillators, cardiac resynchronization defibrillators, and ventricular assist devices. As a result, the best treatment recommendations for females in these fields are currently guided by outcomes evaluated primarily in males. Conclusions: Female enrollment in device clinical trials for coronary revascularization and heart failure has lagged, leaving uncertainty in making benefit/risk assessments of device therapy. The predictors of female nonparticipation in clinical trials can inform a comprehensive strategy to facilitate and enrich the enrollment of females in cardiovascular device trials. This is critical to ensure that sex differences can be considered in treatment selection, so that patients can receive the best available care.
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Affiliation(s)
- Mohammed Imran Ghare
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniela Tirziu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jinnette Dawn Abbott
- Department of Medicine, Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Elissa Altin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yiping Yang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vivian Ng
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York, USA
| | - Cindy Grines
- Northside Cardiovascular Institute, Atlanta, Georgia, USA
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Barts Heart Center, St Bartholomew's Hospital and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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21
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Effects of Medicaid expansion on access, treatment and outcomes for patients with acute myocardial infarction. PLoS One 2020; 15:e0232097. [PMID: 32324827 PMCID: PMC7179915 DOI: 10.1371/journal.pone.0232097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 04/07/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Uninsured patients have decreased access to care, lower rates of percutaneous coronary intervention (PCI), and worse outcomes after acute myocardial infarction (AMI). The aim of this study was to determine whether expanding insurance coverage through the Affordable Care Act's expansion of Medicaid eligibility affected access to PCI hospitals, rates of PCI, 30-day readmissions, and in-hospital mortality after AMI. METHODS Quasi-experimental, difference-in-differences analysis of Medicaid and uninsured patients with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act, and Florida, which did not, from 2010-2015. This study accounts for the early expansion of Medicaid in certain California counties that began as early as July 2011. Main outcomes included rates of admission to PCI hospitals, rates of transfer for patients who initially presented to non-PCI hospitals, rates of PCI, rates of early PCI defined as within 48 hours of hospital admission, in-hospital mortality, and 30-day readmission. RESULTS 55,991 hospital admissions between 2010-2015 met inclusion criteria. Of these, 32,540 were in California, which expanded Medicaid, and 23,451 were in Florida, which did not. 30-day readmission rates after AMI decreased by an absolute difference of 1.22 percentage points after the Medicaid expansion (95% CI -2.14 to -0.30, P < 0.01). This represented a relative decrease in readmission rates of 9.5% after AMI. No relationship between the Medicaid expansion and admission to PCI hospitals, transfer to PCI hospitals, rates of PCI, rates of early PCI, or in-hospital mortality were observed. CONCLUSIONS Hospital readmissions decreased by 9.5% after the Affordable Care Act expanded Medicaid eligibility, although there was no association found between Medicaid expansion and access to PCI hospitals or treatment with PCI. Better understanding the ways that Medicaid expansion might affect care for vulnerable populations with AMI is important for policymakers considering whether to expand Medicaid eligibility in their state.
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22
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Patel N, Gupta A, Doshi R, Kalra R, Bajaj NS, Arora G, Arora P. In-Hospital Management and Outcomes After ST-Segment-Elevation Myocardial Infarction in Medicaid Beneficiaries Compared With Privately Insured Individuals. Circ Cardiovasc Qual Outcomes 2020; 12:e004971. [PMID: 30606054 DOI: 10.1161/circoutcomes.118.004971] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medicaid expansion among previously uninsured individuals has led to improved healthcare access. However, considerably lower reimbursement rates of Medicaid have raised concerns on the unintended consequence of lower utilization of life-saving therapies and inferior outcomes compared with private insurance. We examined the rates of revascularization and in-hospital mortality among Medicaid beneficiaries versus privately insured individuals hospitalized with ST-segment-elevation myocardial infarction (STEMI). METHODS AND RESULTS We queried the National Inpatient Sample from 2012 to 2015 for STEMI hospitalizations with Medicaid or private insurance as primary payer. Hospitalizations with the following criteria were excluded: (1) age <18 or ≥65 years, (2) transfer to another acute care facility, and (3) left against medical advice. Outcomes were compared in propensity score-matched cohort based on demographics, socioeconomic status (income based), clinical comorbidities, including drug and alcohol use, STEMI acuity (cardiac arrest and cardiogenic shock), and hospital characteristics. A total of 42 645 and 171 545 STEMI hospitalizations were identified as having Medicaid and private insurance, respectively. In unadjusted analyses, Medicaid beneficiaries with STEMI had lower rates of coronary revascularization (88.9% versus 92.3%; odds ratio, 0.67; 95% CI, 0.65-0.70) and higher rates of in-hospital mortality (4.9% versus 2.8%; odds ratio, 1.81; 95% CI, 1.72-1.91) compared with privately insured individuals ( P<0.001 for both). In propensity-matched cohort of 40 870 hospitalizations per group, similar results for lower rates of revascularization (89.1% versus 91.1%; odds ratio, 0.80; 95% CI, 0.76-0.84) and higher in-hospital mortality (4.9% versus 3.7%; odds ratio, 1.35; 95% CI, 1.26-1.45) were observed in Medicaid compared with private insurance, despite extensive matching ( P<0.001 for both). CONCLUSIONS Medicaid beneficiaries with STEMI had lower rates of revascularization, although small absolute difference, and higher in-hospital mortality compared with privately insured individuals. Further studies are needed to identify and understand the variation in STEMI outcomes by insurance status.
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Affiliation(s)
- Nirav Patel
- Division of Cardiovascular Disease, University of Alabama at Birmingham Birmingham, AL (N.P., N.S.B., G.A., P.A.)
| | - Ankur Gupta
- Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., N.S.B.)
| | - Rajkumar Doshi
- Department of Internal Medicine, Reno School of Medicine, University of Nevada, Reno, NV (R.D.)
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, MN (R.K.)
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham Birmingham, AL (N.P., N.S.B., G.A., P.A.).,Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.G., N.S.B.)
| | - Garima Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham Birmingham, AL (N.P., N.S.B., G.A., P.A.)
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham Birmingham, AL (N.P., N.S.B., G.A., P.A.).,Section of Cardiology, Birmingham Veterans Affairs Medical Center, AL (P.A.)
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23
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Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020; 141:e139-e596. [PMID: 31992061 DOI: 10.1161/cir.0000000000000757] [Citation(s) in RCA: 4939] [Impact Index Per Article: 1234.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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24
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Kim DY, Wala Z, Islam S, Islam R, Ahn M. Clinical characteristics and outcomes of ST-segment elevation myocardial infarction in a low income setting in rural Bangladesh. IJC HEART & VASCULATURE 2019; 23:100376. [PMID: 31193421 PMCID: PMC6527896 DOI: 10.1016/j.ijcha.2019.100376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/03/2019] [Accepted: 05/04/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND In rural areas of Bangladesh, the majority of patients with ST segment elevation myocardial infarction (STEMI) have little access to reperfusion therapy. Even though thrombolysis can be an affordable life-saving treatment in a low income setting, there are few publications in regards to the clinical and socioeconomic features of STEMI with thrombolytic therapy in rural Bangladesh. METHOD The information of the patients who were admitted for STEMI between 2010 and 2016 from one rural hospital were collected and reviewed. This audit evaluated clinical outcomes and socioeconomic characteristics of the patients. RESULT 164 patients with STEMI were identified in the period and 136 patients (82.93%) underwent thrombolysis. The mean pain-to-door time was 472 min (7.87 h ± 12.40). Only 5.49% of the patients traveled to hospital by ambulances. Overall in-hospital mortality rate and major adverse cardiovascular event (MACE) after STEMI were 19.51% (32/164), 23.17% (38/164), respectively. The need of inotropics (Odds ratio [OR] 16.43, 95% confidence interval [CI] 1.99-135.75, P < 0.01), the use of defibrillation due to ventricular arrhythmias (OR 33.58, 95% CI 2.96-380.49, P < 0.01) were independent predictors of increased in-hospital mortality. CONCLUSION In a rural hospital of Bangladesh, in-hospital mortality rate after STEMI is high in spite of thrombolysis and adherence to published guidelines. The prolonged pain-to-door time and the poor coverage of ambulance services in our study highlight the need of community awareness of acute coronary syndrome and comprehensive emergency medical services in rural Bangladesh.
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Affiliation(s)
- Dong-Yeon Kim
- Corresponding author at: Department of Internal Medicine, LAMB Hospital, Rajabashor, Parbatipur, Dinajpur 5250, Bangladesh.
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25
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Burton BN, Abudu B, Danforth DJ, Patell S, Wilkins Y Martinez L, Fergerson B, Elsharydah A, Gabriel RA. Prediction Model for Extended Hospital Stay Among Medicare Beneficiaries After Percutaneous Coronary Intervention. J Cardiothorac Vasc Anesth 2019; 33:3035-3041. [PMID: 31122844 DOI: 10.1053/j.jvca.2019.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The authors conducted a retrospective analysis to develop a predictive model consisting of factors associated with extended hospital stay among Medicare beneficiaries undergoing percutaneous coronary intervention (PCI). DESIGN Retrospective cohort study. SETTING Multi-institutional. PARTICIPANTS Data were obtained from the National (Nationwide) Inpatient Sample registry from 2013 to 2014 over a 2-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was extended hospital stay, which was defined as an inpatient stay greater than 75th percentile for the cohort (≥5 d), among Medicare beneficiaries (fee-for-service and managed care) undergoing PCI. A multivariable logistic regression analysis was built on a training set to develop the predictive model. The authors evaluated model performance with area under the receiver operating characteristic curve (AUC) and performed k-folds cross-validation to calculate the average AUC. The final analysis included 91,880 patients. Inpatient hospital length of stay ranged from 0 to 247 days, with 3 and 5 days as the median and 3rd quartile hospital stay, respectively. The final multivariable analysis suggested that sociodemographic variables, hospital-related factors, and comorbidities were associated with a greater odds of extended hospital stay (all p < 0.05). The use of PCI with drug-eluting stent was associated with a 31% decrease in extended hospital stay (odds ratio 0.69, 95% confidence interval 0.66-0.72; p < 0.001). Model discrimination was deemed excellent with an AUC (95% confidence interval) of 0.814 (0.811-0.817) and 0.809 (0.799-0.819) for the training and testing sets, respectively. CONCLUSION The authors' predictive model identified risk factors that have a higher probability of extended hospital stay. This model can be used to improve periprocedural optimization and improved discharge planning, which may help to decrease costs associated with PCIs. Management of Medicare beneficiaries after PCI calls for a multidisciplinary approach among healthcare teams and hospital administrators.
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Affiliation(s)
- Brittany N Burton
- School of Medicine, University of California San Diego, San Diego, CA
| | - Boya Abudu
- School of Medicine, University of California San Diego, San Diego, CA
| | - Dennis J Danforth
- Department of Anesthesiology, University of California, San Diego, San Diego, CA
| | - Saatchi Patell
- School of Medicine, University of California San Diego, San Diego, CA
| | | | - Byron Fergerson
- Department of Anesthesiology, University of California, San Diego, San Diego, CA
| | - Ahmad Elsharydah
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, CA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, San Diego, CA.
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26
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Steele L, Palmer J, Lloyd A, Fotheringham J, Iqbal J, Grech ED. Impact of socioeconomic status on survival following ST-elevation myocardial infarction in a universal healthcare system. Int J Cardiol 2019; 276:26-30. [DOI: 10.1016/j.ijcard.2018.11.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/02/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
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27
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Association between insurance status, anticoagulation quality, and clinical outcomes in patients with acute venous thromboembolism. Thromb Res 2019; 173:124-130. [DOI: 10.1016/j.thromres.2018.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/01/2018] [Accepted: 11/11/2018] [Indexed: 11/19/2022]
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28
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Brindis CD, Freund KM. The ramifications of recent health policy actions for cardiovascular care of women: Progress, threats, and opportunities. Clin Cardiol 2018; 41:173-178. [PMID: 29485710 DOI: 10.1002/clc.22896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 01/07/2018] [Indexed: 11/07/2022] Open
Abstract
Women's health and well-being are shaped by a combination of healthcare policies that impact the type of health insurance coverage they benefit from, as well as access to preventive, screening, and treatment services. Furthermore, more distal policies, such as those that pertain to housing, education, and employment, as well as social determinants of health, such as issues of socioeconomic status and women's status in society, also impact their cardiac health. Before the passage of the Affordable Care Act in 2010, women were at greater risk of facing barriers to coverage, reflecting gender rating and the higher likelihood of the existence of preexisting health conditions such as a previous pregnancy. The ACA made substantial progress in responding to women's health needs by expanding the numbers of low-income groups eligible for Medicaid (for the 32 states and Washington, DC that expanded the program) and other subsidized healthcare, as well as access to preventive health services. Although health reform efforts to eliminate the ACA failed in 2016, the administration and Congress are using a variety of channels, including the new Tax Cuts and Job Act, to implement policies such as the elimination of the individual insurance mandate, as well as the elimination of premium subsidies, that will likely impact women differentially, potentially undoing the progress that has been achieved over the past decade.
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Affiliation(s)
- Claire D Brindis
- Philip R. Lee Institute for Health Policy Studies, Department of Pediatrics, Department of Obstetrics, Gynecology and Reproductive Health Sciences, University of California, San Francisco, California
| | - Karen M Freund
- Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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