Abstract 13350: Primary Payer Status Influences Management and Outcomes in Non-ST Elevation Myocardial Infarction

Abstract

Introduction: Multiple previous studies have shown that insurance status of the patient impacts the management and overall outcomes of patients presenting with acute myocardial infarction. There are limited data on the impact of primary payer status in patients with non ST segment elevation myocardial infarction (NSTEMI). Hypothesis: Primary payer status influences management and overall outcomes independent of the clinical and hospital-based characteristics in NSTEMI patients. Methods and Results: Adult (>18 years) NSTEMI 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, early coronary angiography and percutaneous coronary intervention (PCI), resource utilization, and discharge disposition. 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, the Medicare cohort was older (76 vs. 53-60 years), more often female (48% vs. 25-44%), of white race, and with higher comorbidity (all p <0.001). The Medicare cohort had higher in-hospital mortality (5.6%) compared to the other groups (1.9-3.4%), p <0.001. In a multivariable analysis (Medicare 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 0.0.94-1.00]; p =0.06). Coronary angiography (overall 52% vs. 65-74%; early 15% vs. 22-27%) and PCI (27% vs. 35-44%) were used less frequently in the Medicare population. The Medicare population had longer lengths of hospital stay, lowest hospitalization costs and fewer discharges to home. 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.