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High Deductibles and ED Evaluation of Nonspecific Chest Pain
Quick Takes
- High-deductible health plans (HDHPs) impact decision making related to seeking emergency department (ED) care for nonspecific chest pain and subsequent admission to the hospital.
- HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.
Study Questions:
How do high-deductible health plans (HDHPs) impact emergency department (ED) visits and subsequent care after an ED diagnosis of nonspecific chest pain?
Methods:
Using a commercial and Medicare Advantage claims database, members 19-63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1,000) for a subsequent year were matched with contemporaneous members whose employers only offered low-deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. Analysis included cumulative interrupted time-series analysis, comparing changes in annual outcomes between the HDHP and control groups before and after the index date using aggregate-level segmented regression. Members from higher-poverty neighborhoods were a subgroup of interest.
Results:
After matching, 557,501 members in the HDHP group and 5,861,990 in the control group were included and had a mean age of 42.0 years, 48-49% female, and 67-68% non-Hispanic white. Employer-mandated HDHP switches were associated with a relative decrease of 4.3% (95% confidence interval [CI], –5.9 to –2.7; absolute change, –4.5 [95% CI, –6.3 to –2.8] per 10,000 person-years) in nonspecific chest pain ED visits and 11.3% (95% CI, –14.0 to –8.6) decrease (absolute change, –1.7 per 10,000 person-years [95% CI, –2.1 to –1.2]) in visits leading to hospitalization. There was no significant decrease in subsequent noninvasive testing or revascularization procedures. An increase in 30-day acute myocardial infarction admissions was not statistically significant (15.9% [95% CI, –1.0 to 32.7]; absolute change, 0.3 per 10,000 person-years [95% CI, –0.01 to 0.5]), but was significant among members from higher-poverty neighborhoods.
Conclusions:
Employer-mandated HDHP switches were associated with decreased nonspecific chest pain ED visits and hospitalization from these ED visits, but no significant change in post-ED cardiac testing. However, HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.
Perspective:
Findings suggest that having an HDHP impacts decision making about seeking ED care for nonspecific chest pain and subsequent admission to the hospital. There was no significant change in subsequent cardiac testing. Rates of acute myocardial infarction within 30 days among patients with HDHP were increased among members from lower socioeconomic groups. Findings highlight another complexity in how best to integrate cost of care into appropriate clinical decision making, especially in lower-income earners.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Chest Pain, Coronary Angiography, Deductibles and Coinsurance, Diagnostic Tests, Routine, Emergency Service, Hospital, Health Care Costs, Income, Myocardial Infarction, Myocardial Revascularization, Poverty, Secondary Prevention, Socioeconomic Factors, Tomography
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