Study Looks at AMI Care in French Universal Coverage System

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The French system of free universal health coverage levels the playing field in terms of early treatment and outcomes for socially disadvantaged patients with acute myocardial infarction (AMI), but cannot prevent worsening patterns of care over the long term, according to a study published online October 4, 2011, ahead of print in Circulation: Cardiovascular Quality and Outcomes.

Researchers led by Nicolas Danchin, MD, of Hôpital Européen Georges Pompidou (Paris, France), looked at AMI patients under age 60 hospitalized from January to June 2006 in France who were (n = 587) or were not (n = 4,352) covered under the French National Health Insurance system program that provides free, supplemental insurance for low-income earners (< € 7,447 annually, or < $9,971 US).

Dr. Danchin and colleagues sought to determine whether the French national coverage system could level socioeconomic inequalities in treatment and outcomes. The program for free universal insurance covers total medical expenditures, including the fee for each day spent in the hospital without requiring advance payment.

As one would expect, patients in the universal coverage group were markedly dissimilar to the other subjects, leading to several baseline differences. For instance, universal coverage patients had more comorbidities and were younger at the time of presentation. Overall, patients receiving universal coverage showed lower rates of PCI and stenting compared to patients not on the program, with equivalent in-hospital mortality (table 1).

Table 1. In-hospital Treatment and Mortality Rates

 

Universal Coverage
(n = 587)

No Universal Coverage
(n = 4,352)

P Value

Coronary Angiography

91.1%

93.1%

0.082

PCI

73%

78%

< 0.02

Stenting

70.0%

74.6%

0.017

CABG

1.7%

1.6%

0.897

Mortality

3.1%

2.8%

0.694


However, after adjustment for multiple factors including age, sex, associated conditions, and region, the use of cardiac catheterization and coronary interventions was similar between patients with and without free coverage (adjusted RR 0.97; 95% CI 0.91-1.05; P = 0.45). Universal coverage and non-universal coverage patients were admitted to the same types of institutions, including academic hospitals (40% and 38%, respectively) and private clinics (22% and 23%, respectively). There also were no differences regarding low- and high-volume institutions.

During the first 6 months after hospitalization, similar proportions of patients with vs. without universal coverage had consultations with cardiologists, both in private practice/clinic (adjusted RR 0.98; 95% CI 0.87-1.09; P = 0.66) and overall (adjusted HR 0.96; 95% CI 0.89-1.02; P = 0.19). Medication use showed some small differences, with universal coverage patients less often taking some drugs such as clopidogrel (85.2% vs. 88.5%; P = 0.025) and statins (89.1% vs. 93.6%; P = 0.002). These differences, though, disappeared after adjustment.

Longer Term Inequalities Still Exist

Out to 30 months, adherence to statin therapy was significantly lower in patients on universal coverage, a difference that persisted after multivariable adjustment (RR 0.82; 95% CI 0.73-0.92; P < 0.001). Universal coverage patients also consulted cardiologists less frequently, especially those in private practice (0.83/year vs. 1.06/year; P < 0.0001).

Thirty-day rates of all-cause mortality, death or hospitalization for ACS, and death or myocardial revascularization were all higher in patients with universal coverage, but these differences disappeared after multivariable adjustment, leaving only a trend for increased death or hospitalization for ACS (HR 1.21; 95% CI 0.94-1.57; P = 0.14).

“Inequalities in health care constitute a major ethical and political issue,” the researchers note. “The current study suggests that providing access to full medical coverage for socially deprived populations can level such inequalities in patients hospitalized for acute conditions such as AMI.”

 Still, despite the success in ameliorating disparities in the short term, full medical coverage “was not sufficient to ensure optimal long-term medical care,” the authors point out. “[A]dherence to statin therapy was less in [fully covered] patients, despite the fact that the medications could be delivered at no cost.”

Clearly, additional measures are necessary, such as patient education regarding medication adherence and lifestyle modification efforts aimed at risk factors for this population, the authors say. They stress that their findings cannot be extrapolated outside the AMI system of care, or to other countries.

 


Source:
Danchin N, Neumann A, Tuppin P, et al. Impact of free universal medical coverage on medical care and outcomes in low-income patients hospitalized for acute myocardial infarction: An analysis from the French National Health Insurance System. Circ Cardiovasc Qual Outcomes. 2011;Epub ahead of print.

 

Disclosures:

  • Dr. Danchin reports serving as the past chairman of the scientific committee of the French National Health Insurance system, and receiving lecture/consulting fees, and grant support from numerous pharmaceutical companies.

 

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