Abstract

BackgroundThere are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI).ObjectiveTo assess the influence of insurance status on STEMI outcomes.MethodsAdult (>18 years) STEMI 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 and percutaneous coronary intervention (PCI), hospitalization costs, hospital length of stay and discharge disposition.ResultsOf the 4,310,703 STEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively. Compared to the others, the Medicare cohort was older (75 vs. 53–57 years), more often female (46% vs. 20–36%), of white race, and with higher comorbidity (all p<0.001). The Medicare and Medicaid population had higher rates of cardiogenic shock and cardiac arrest. The Medicare cohort had higher in-hospital mortality (14.2%) compared to the other groups (4.1–6.7%), p<0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in uninsured (adjusted odds ratio (aOR) 1.14 [95% confidence interval {CI} 1.11–1.16]), and lower in Medicaid (aOR 0.96 [95% CI 0.94–0.99]; p = 0.002), privately insured (aOR 0.73 [95% CI 0.72–0.75]) and other insurance (aOR 0.91 [95% CI 0.88–0.94]); all p<0.001. Coronary angiography (60% vs. 77–82%) and PCI (45% vs. 63–70%) were used less frequently in the Medicare population compared to others. The Medicare and Medicaid populations had longer lengths of hospital stay, and the Medicare population had the lowest hospitalization costs and fewer discharges to home.ConclusionsCompared to other types of primary payers, STEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.

Highlights

  • Ischemic heart disease and acute myocardial infarction continue to be leading cause of cardiovascular admissions in the United States [1,2,3,4]

  • Of the 4,310,703 segment elevation myocardial infarction (STEMI) admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively

  • Despite the improvements in early coronary angiography and prompt percutaneous coronary intervention (PCI), STEMI continues to be associated with considerable mortality and morbidity

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Summary

Introduction

Ischemic heart disease and acute myocardial infarction continue to be leading cause of cardiovascular admissions in the United States [1,2,3,4]. In patients with STEMI, large retrospective studies have previously demonstrated the lack of health insurance and Medicaid status to be associated with worse mortality and higher readmission rates compared to patients with private insurance [7, 10, 11]. While this may be partially be due to socioeconomic factors, other contributing factors include lifestyle issues, a lack of access to care in uninsured populations, and a higher burden of comorbidities and issues with medication adherence in Medicaid populations that preclude PCI [7, 10]. There are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI)

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