Influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction in the United States

Vallabhajosyula, Saraschandra; Kumar, Vinayak; Sundaragiri, Pranathi R.; Cheungpasitporn, Wisit; Bell, Malcolm R.; Singh, Mandeep; Jaffe, Allan S.; Barsness, Gregory W.

doi:10.1371/journal.pone.0243810

Cited by 7 publications

(10 citation statements)

References 37 publications

(47 reference statements)

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“…Besides, we used validated codes that have been used extensively in prior studies using the NIS. 31 , 32 Second, the NIS does not capture pharmacotherapy, echocardiography, or angiographic data. Thus, granular information on the differences in antithrombotic regimes, ejection fraction, successful versus unsuccessful PCI, and reasons for not performing PCI is not available.…”

Section: Discussionmentioning

confidence: 99%

Treatment Effect of Percutaneous Coronary Intervention in Men Versus Women With ST‐Segment–Elevation Myocardial Infarction

Sulaiman

Kawsara

Mohamed

et al. 2021

JAHA

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Background Women are less likely to receive primary percutaneous coronary intervention (pPCI) than men. A potential reason is risk aversion because of the worse outcomes with pPCI among women. However, whether pPCI is associated with a comparable mortality benefit in men and women remains unknown. Methods and Results We selected patients admitted with a principal diagnosis of ST‐segment–elevation myocardial infarction in the National Inpatient Sample (2016–2018). We used propensity‐score matching to calculate average treatment effects of pPCI for in‐hospital mortality, major complications, length of stay, and cost. As a sensitivity analysis, we used logit models followed by a marginal command to calculate the average marginal effect. We included 413 500 weighted hospitalizations (30.7% women, 69.3% men). Women had more comorbidities except smoking and prior sternotomy. Compared with men, women were less likely to undergo angiography (81.0% versus 87.0%; adjusted odds ratio [OR], 0.77; 95% CI, 0.74–0.81; P <0.001) or pPCI (74.0% versus 82.0%; adjusted OR, 0.76; 95% CI, 0.73–0.79; P <0.001). There were no significant differences in average treatment effects of pPCI on mortality between men (−8.4% [−9.3% to −7.6%], P <0.001), and women (−9.5% [−10.8% to −8.3%], P <0.001) ( P interaction=0.16). This persisted in age‐stratified analyses (≥85, 65–84, 45–64, <45 years) and sensitivity analysis, excluding emergent admissions. The average treatment effects of pPCI on major complications were comparable except for acute stroke, leaving against medical advice, and palliative encounter. There were no differences in the average treatment effects of pPCI on length of stay, but the proportional increase in cost with pPCI was higher in women. Conclusions pPCI results in a comparable reduction in in‐hospital mortality in men and women. Nonetheless, risk‐adjusted rates of pPCI remain lower in women in contemporary US practice.

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Section: Discussionmentioning

confidence: 99%

Treatment Effect of Percutaneous Coronary Intervention in Men Versus Women With ST‐Segment–Elevation Myocardial Infarction

Sulaiman

Kawsara

Mohamed

et al. 2021

JAHA

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“…Specifically, Medicare patients are older and have higher comorbidities, and therefore may receive less frequent guideline-directed therapies because of risk of complications. 6,7 In contrast, though Medicaid patients are younger, hospitals are reimbursed lesser for Medicaid patients, raising concerns that they might systematically receive less aggressive therapy. 1,2 Cardiogenic shock (CS) constitutes the sickest spectrum of AMI, and continues to be associated with nearly 30% to 40% mortality and morbidity in the contemporary era.…”

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confidence: 99%

“…Typically, privately insured individuals receive the most aggressive care when presenting with an AMI and, therefore, it is important to contrast the outcomes of uninsured group against this insurance group. 1,2,6,7 Considering this background, using a nationally representative population, we sought to assess the management and outcomes of uninsured individuals compared with privately insured individuals presenting with AMI-CS. In addition, we evaluated the temporal trends in admissions, use of cardiac and noncardiac procedures, and clinical outcomes of these populations.…”

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confidence: 99%

“…2,4,5 Age impacts primary payer status, with a larger proportion of non-ST-segment AMI patients bearing Medicare insurance, whereas patients with ST-segment-elevation AMI have other forms of insurance. 6,7 Prior data from the AMI literature has noted insurance-specific differences between those with Medicare and Medicaid and other carriers. Specifically, Medicare patients are older and have higher comorbidities, and therefore may receive less frequent guideline-directed therapies because of risk of complications.…”

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confidence: 99%

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Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared With Privately Insured Individuals

Vallabhajosyula

Kumar

Sundaragiri

et al. 2022

Circ: Heart Failure

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Background: There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. Methods: Using the National Inpatient Sample (2000–2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer—self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. Results: Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P <0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13–1.17]; P <0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83–0.87]; P <0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P <0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55–1.68]; P <0.001) and resource utilization. Conclusions: Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.

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“…20 Furthermore, it has been previously shown that socioeconomic characteristics such as 'primary expected payer' status and 'median household income' are associated with worse outcomes in patients with principal discharge diagnosis of AMI through disparities in the receipt of evidence-based therapies and guideline recommended care. 21,22 However, in order to diminish the influence of these variables, we have conducted a multivariable logistic regression analysis and adjusted for them.…”

Section: Discussionmentioning

confidence: 99%

Distribution, management and outcomes of AMI according to principal diagnosis priority during inpatient admission

et al. 2021

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Background: In recent years, there has been a growing interest in outcomes of patients with acute myocardial infarction (AMI) using large administrative datasets. The present study was designed to compare the characteristics, management strategies and acute outcomes between patients with primary and secondary AMI diagnoses in a national cohort of patients.Methods: All hospitalisations of adults (≥18 years) with a discharge diagnosis of AMI in the US National Inpatient Sample from January 2004 to September 2015 were included, stratified by primary or secondary AMI. The International Classification of Diseases, ninth revision and Clinical Classification Software codes were used to identify patient comorbidities, procedures and clinical outcomes.Results: A total of 10 864 598 weighted AMI hospitalisations were analysed, of which 7 186 261 (66.1%) were primary AMIs and 3 678 337 (33.9%) were secondary AMI.Patients with primary AMI diagnoses were younger (median 68 vs 74 years, P < .001) and less likely to be female (39.6% vs 48.5%, P < .001). Secondary AMI was associated with lower odds of receipt of coronary angiography (aOR 0.19; 95%CI 0.18-0.19) and percutaneous coronary intervention (0.24; 0.23-0.24). Secondary AMI was as-

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Influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction in the United States

Cited by 7 publications

References 37 publications

Treatment Effect of Percutaneous Coronary Intervention in Men Versus Women With ST‐Segment–Elevation Myocardial Infarction

Treatment Effect of Percutaneous Coronary Intervention in Men Versus Women With ST‐Segment–Elevation Myocardial Infarction

Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared With Privately Insured Individuals

Distribution, management and outcomes of AMI according to principal diagnosis priority during inpatient admission

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