Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction

Abstract

Context: Little is known about how health insurance status affects decisions to seek care during emergency medical conditions such as acute myocardial infarction (AMI).

Objective: To examine the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during AMI.

Design, setting, and patients: Multicenter, prospective study using a registry of 3721 AMI patients enrolled between April 11, 2005, and December 31, 2008, at 24 US hospitals. Health insurance status was categorized as insured without financial concerns, insured but have financial concerns about accessing care, and uninsured. Insurance information was determined from medical records while financial concerns among those with health insurance were determined from structured interviews.

Main outcome measure: Prehospital delay times (< or = 2 hours, > 2-6 hours, or > 6 hours), adjusted for demographic, clinical, and social and psychological factors using hierarchical ordinal regression models.

Results: Of 3721 patients, 2294 were insured without financial concerns (61.7%), 689 were insured but had financial concerns about accessing care (18.5%), and 738 were uninsured (19.8%). Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI and had prehospital delays of greater than 6 hours among 48.6% of uninsured patients and 44.6% of insured patients with financial concerns compared with only 39.3% of insured patients without financial concerns. Prehospital delays of less than 2 hours during AMI occurred among 36.6% of those insured without financial concerns compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients (P < .001). After adjusting for potential confounders, prehospital delays were associated with insured patients with financial concerns (adjusted odds ratio, 1.21 [95% confidence interval, 1.05-1.41]; P = .01) and with uninsured patients (adjusted odds ratio, 1.38 [95% confidence interval, 1.17-1.63]; P < .001).

Conclusion: Lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.

Figure 1. Study Definition of Financial Concerns in those with Health Insurance

Insured patients in the study were categorized as having financial concerns in accessing care if, because of costs, they avoided medical care, taking medications, or had difficulties accessing care.

Figure 2. Adjusted Cumulative Probabilities for Covariates in Final Multivariable Model for Prehospital Delays

Odds ratios in the model represent cumulative probabilities between a predictor variable and each combination of higher risk versus lower risk outcome categories (e.g., >6 hours vs. ≤6 hours and >2 hours vs. ≤2 hours). Error bars denote 95% confidence intervals. Abbreviations: CABG, coronary artery bypass grafting; CAD, coronary artery disease; MI, myocardial infarction; PCI, percutaneous coronary interventions; SAQ, Seattle Angina Questionnaire. ^a Reference categories for the following variables: (1) Insurance status: Insured without financial concerns; (2) Marital status: Married; (3) Educational level: Graduate School; (4) Residential area: Urban; (5) Killip class: Killip class III or IV; (6) Time of hospital arrival: Weekend; (7) SAQ Angina frequency: No angina; (8) PHQ Depressive symptoms: Not depressed.