This post is brought to Lewin Report readers from Dr. Ralph Brindis, ACC's current president. Dr. Brindis is the
Senior Advisor for Cardiovascular Disease for Northern California Kaiser
Clinical Professor of Medicine at the University of California-San
Francisco. Dr. Brindis has previously posted on this blog about NCDR and coverage with evidence development.
Un- or under-insured patients
are more likely to delay seeking emergency care for an AMI (or heart attack,
for our non-cardiovascular professional readers), according to a study that
came out yesterday afternoon in JAMA.
Using data from 3,721 AMI
patients accessing care between April 2005 and December 2008 at 24 hospitals,
researchers determined that 44.6 percent of patients with financial concerns
and 48.6 percent of uninsured patients, compared to 39.3 of insured patients
without financial concerns, waited MORE THAN 6 HOURS from the onset of their
symptoms to seek medical care.
In heart attack treatment,
time between symptom onset and treatment is a matter of life or death. The
authors recognize this in their paper:
prehospital delays are associated with higher AMI morbidity and mortality,
demonstrating that patients’ [insurance status can put them] at higher risk for
prehospital delays is important because it would suggest that reducing
financial barriers to care ... could reduce delays and improve outcomes.”
Health Care Reform Potential
As the D2B Alliance has shown us, optimal AMI care involves receiving treatment
within the first 90 minutes of arriving at the hospital. But the improved
outcomes this speedy treatment can provide are limited if the patient waits
more than six hours to come in for treatment.
The recently passed health
care reform law could help out in this regard. Through its insurance reforms,
it is predicted that millions will gain access to health insurance. However, as
this study indicates, it’s not enough to have health insurance; patients also
must have health insurance without financial concerns. With the expanded access
to insurance, this study indicates that we potentially have a unique
opportunity to help improve outcomes for patients with emergency conditions by
reducing delays in treatment, and reducing the stress that comes with having to
choose between seeking treatment and maintaining financial stability.
Other Causes of Delays
Some patients are leery about
calling 9-1-1 and emergency ambulance services not just due to inappropriate
concern about potential ambulance costs to themselves and their families but
also lack of heart attack symptom awareness. Terrific systems of care now
already in place to offer timely heart attack care need to find ways of being
fully effective for all our patients. This requires improved patient education
and awareness about heart attack symptoms (which can be assisted through ACC’s
patient education portal, CardioSmart); improved access to
care in general; and, importantly, societal programs to improve socioeconomic
This important study describing
disparities in care related to socioeconomic status provides health care
providers extra motivation to improve care for the disadvantaged.
Finally, the authors note
that although the findings of the study only directly address AMI care, they
may speak to other medical conditions. It’s quite possible that patients also
may delay treatment for other medical conditions requiring speedy treatment because
of financial concerns, such as stroke, pneumonia and appendicitis. They write,
“As a result interventions that broaden and ensure the affordability of health
insurance coverage in the United
States may reduce times to presentation for
all emergent medical conditions.” We’ll find out over the next couple of years
if the insurance reform in the new health care law will help reduce these times
and therefore improve outcomes.
-- Ralph Brindis, M.D., F.A.C.C.