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 and a 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.

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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:

“Because 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 status.

This important study describing disparities in care related to socioeconomic status provides health care providers extra motivation to improve care for the disadvantaged. 

Study Implications
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.

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