NCDR Study Shows Uninsured Outpatients Less Likely to Receive Evidence-Based Therapies for CAD

A study published on Jan. 30 in the Journal of the American College of Cardiology found that uninsured patients are less likely to receive evidence-based medications for coronary artery disease (CAD) than patients with private or public insurance.

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The study used 60,814 patients with obstructive CAD in the NCDR's PINNACLE Registry® to examine outpatient care. Results showed uninsured patients were less likely to receive beta-blocker therapy after myocardial infarction compared to those who had private health insurance (unadjusted risk ratio 0.91, p<0.0001). Uninsured patients also were less likely to receive lipid-lowering therapy (unadjusted RR 0.94, p<0.0001) and angiotensin-converting enzyme inhibitor (ACE-I)/ angiotensin receptor blocker (ARB) drugs (unadjusted RR 0.88, p<0.0001).

In addition, there were no significant differences between the uninsured and those with private insurance for antiplatelet and thienopyridine therapy. Public insurance patients were less likely than private insurance patients to receive ACE-I/ARB, but there were no other significant differences between insurance types.

"Coronary artery disease is a prevalent and burdensome disease for which there is compelling evidence for the use of secondary prevention," said lead author Kim Smolderen, PhD, affiliate member of the ACC, of Saint Luke's Mid America Heart Institute, Kansas City, Mo. "[Results showed that] uninsured patients were less likely to receive evidence-based medications for CAD, including beta-blocker, ACE-I, or ARB and lipid-lowering therapy as compared with insured patients."

"Lower rates of treatment with evidence-based medications for CAD in uninsured patients reflect not only poor care but also cost-inefficient care," Smolderen added. "Given the high risk for cardiovascular events in patients with a history of CAD, the development of mechanisms to ensure that uninsured patients have access to care and medication treatment would improve the quality of overall care without necessarily increasing overall treatment costs."

In an accompanying editorial comment, Edward Havranek, MD, FACC, Denver Health Center, University of Colorado School of Medicine, Denver, notes, "it is prescription rates, not medication rates that are low. With the widespread availability of inexpensive generic alternatives for beta-blockers, ACE-I/ARB agents and lipid-lowering drugs, it should be uncommon for physicians not to offer prescriptions for these medications. We will need to strengthen infrastructure and change practice patterns in ways that improve care."

Keywords: Odds Ratio, Myocardial Infarction, Coronary Artery Disease, Pyridines, Health Care Costs, Registries, Secondary Prevention, Outpatients, Kansas, Health Services Needs and Demand, United States

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