Insurance Type Affects Outcomes After PCI

Patients who have Medicare, Medicaid, or no insurance at all have a higher rate of major adverse cardiac events (MACE) 1 year after percutaneous coronary intervention (PCI) than those with private insurance, according to a study published online December 29, 2010, ahead of print in the American Journal of Cardiology.

Researchers led by Ron Waksman, MD, of the Washington Hospital Center (Washington, DC), retrospectively analyzed data from 13,573 patients who underwent PCI at their institution from June 2000 to June 2009. Among them, 49% had private insurance, 45.3% had Medicare, 3.6% had Medicaid, and 2.1% were uninsured.

Clinical outcomes showed substantial variation across the different groups. Patients with Medicaid, Medicare, or no insurance were more likely to die in-hospital than were patients with private insurance. A similar trend for MACE at 30 days also emerged (P for trend < 0.001 for both endpoints; table 1). These differences remained significant at 1 year, with greater rates of death for patients with Medicaid, Medicare, or no insurance compared to those with private insurance.

Table 1. Clinical Outcomes by Insurance Status

Rates of TVR, Q-wave MI, and stent thrombosis also were greater at 1 year for patients with Medicaid or no insurance compared with Medicare or private insurance.

Younger Patients Fare Worse Without Private Insurance

In patients aged younger than 65 years, multivariable analysis showed that those who had Medicaid, Medicare, and no insurance were more likely to experience MACE than were patients with private insurance (table 2).

Table 2. Risk of MACE for Patients < 65 by Insurance Type

 
Other covariables significantly associated with MACE risk in this population included cardiogenic shock on presentation (HR 4.58; 95% CI 3.12-6.73), congestive heart failure (HR 1.49; 95% CI 1.10-2.02), and systemic hypertension (HR 1.81; 95% CI 1.27-1.59).

However, in the population aged 65 years and older, multivariable analysis found that only Medicaid was associated with greater MACE risk at 1 year (HR 3.07; 95% CI 1.09-8.61). Medicare did not appear to affect MACE risk, and the small number of uninsured patients in this population precluded analysis.

Baseline characteristics also varied according to insurance status. PCI of the left main coronary artery or a saphenous vein graft was more common in Medicare patients, whereas those with private insurance were more likely to have undergone PCI of the left anterior descending artery. Private insurance patients also had a greater likelihood of receiving IVUS-guided PCI. Medicare and private insurance were also associated with bivalirudin use while having Medicaid or lack of insurance were tied to glycoprotein IIb/IIIa inhibitor use. Patients with private insurance also were more likely to have received at least 1 DES (78.2%) compared with those with Medicare (72.0%), no insurance (60.1%), or Medicaid (59.9%; P < 0.001).

Debating the Impact of Insurance Status

In an e-mail communication with TCTMD, Dr. Waksman characterized the similar outcomes for uninsured and government-insured patients as “unexpected” and “surprising.”

The investigators propose in their paper that the disparity between insurance types is likely due to multiple factors that “in concert with insurance, influence both the access to care and patient behavior.” They point to a recent study (Gerber Y. Circulation. 2010;121:375-383) showing that not only individual but also neighborhood socioeconomic status can influence survival after MI. In addition, the authors say, physician-level factors also could influence outcomes.

The take-home message for physicians should be “awareness that patients uninsured or on government insurance are at higher risk to develop subsequent cardiac events,” Dr. Waksman said. “Therefore more time should be devoted to educating patients and assuring compliance.”

Policymakers, meanwhile, should recognize that “health care is not all about insurance. Patients should be motivated and given incentives to take care of themselves to improve their outcome. Don't expect that giving insurance to everyone [will] improve outcome,” he advised.

Deepak L. Bhatt, MD, MPH, of Brigham and Women’s Hospital (Boston, MA), told TCTMD in an e-mail communication that the study is both interesting and complex in its analysis.

“There are several factors (for example, renal failure) that may determine why patients under 65 years of age may be on Medicaid or Medicare, and these factors may be what is causing the worse outcomes seen here, rather than the type of insurance per se,” Dr. Bhatt said. “Nevertheless, I think the authors' conclusion is correct—merely providing insurance coverage is not sufficient to improve cardiovascular outcomes after PCI, and that statement is likely generalizeable to other disease states as well.”

 

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Source:
Gaglia MA, Torguson R, Xue Z, et al. Effect of insurance type on adverse cardiac events after percutaneous coronary intervention. Am J Cardiol. 2010;Epub ahead of print.

 

 

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