CardioExchange Archive

We welcome Kim G. Smolderen, PhD, to answer our questions about her research group’s JAMA study “Health Care Insurance, Financial Concerns in Accessing Care, and Delays to Hospital Presentation in Acute Myocardial Infarction”  Among her coauthors were CardioExchange contributor Dr. Paul S. Chan—who participated in our exchange with Smolderen—and CardioExchange Editor Dr. Harlan M. Krumholz. We encourage you to ask your own questions.

Background: The researchers studied 3721 patients to assess the relation between health insurance status and time from symptom onset to presentation with acute MI at one of 24 U.S. hospitals. Delays of longer than 6 hours were documented in 48.6% of uninsured patients, 44.6% of insured patients who reported financial concerns about access to medical care, and 39.3% of insured patients who did not report such concerns. Delays of 2 hours or less were documented in 27.5%, 33.5%, and 36.6%, respectively. The differences among the groups were statistically significant.

What are your findings’ policy implications for health coverage in the U.S., particularly given the significant differences in prehospital delays between people with insurance who had financial concerns and the uninsured?

Indeed, our data point to a gradient of vulnerability by insurance status. Uninsured patients were the most likely to delay care during a myocardial infarction. Insured patients with financial concerns, often called the “underinsured,” do not delay as much as the uninsured but still wait significantly longer than insured patients without financial concerns. 

Notably, a substantial number of the insured with financial concerns in our study actually had private insurance. This suggests that a market-based system of patient-selected private insurance may not be sufficient to guarantee optimal access to care if it fails to account for out-of-pocket costs, which are rising. The number of insured patients is expected to increase in the wake of recently passed health care legislation, so the number of insured patients with financial concerns may grow. Ultimately, health care reform will need not only to provide coverage for the uninsured but also to ensure that patients can afford to use their existing insurance. 

Many modifiable factors are known to affect prehospital delays, and you also tracked lower education level and depression. Relative to all those factors, how would you weight the relative impact of lack of health insurance and financial concerns? And notwithstanding the interrelatedness of all the factors, which do you think should be priorities in interventions aimed at minimizing prehospital delays?

Among the predictors of prehospital delays that we identified, health insurance status is the one where action can clearly be taken. Public policy that expands coverage or improves affordability has the potential to have a substantial effect. In fact, disparities in prehospital delay by race—a nonmodifiable patient attribute that has been reported as a predictor of prehospital delay—were substantially attenuated after adjustment for insurance status and other patient characteristics in our study.

Previously studied interventions, both at the population level (i.e., the REACT trial) and the patient level, have been unsuccessful in reducing prehospital delays during acute MI. As a result, these delays have hardly changed in the past decade. Although an approach that integrates educational efforts at the patient, community, and national levels is likely to be valuable, it cannot work if public policy efforts fail to address the structural issues of access to—and affordability of—health care.

Of course, there is no magic bullet. A multimodal approach of patient, community, and policy interventions will provide the best chance for getting patients into hospitals promptly to receive potentially life-saving therapies for acute MI and other emergencies.