Influence of primary payer status on non-ST-segment elevation myocardial infarction: 18-year retrospective cohort national temporal trends, management and outcomes

Abstract

Background: The role of insurance on outcomes in non-ST-segment-elevation myocardial infarction (NSTEMI) patients is limited in the contemporary era.Methods: From the National Inpatient Sample, adult NSTEMI admissions were identified [2000][2001][2002][2003][2004][2005][2006][2007][2008][2009][2010][2011][2012][2013][2014][2015][2016][2017].Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes included in-hospital mortality, overall and early coronary angiography, percutaneous coronary intervention (PCI), resource utilization and discharge disposition.Results: Of the 7,290,565 NSTEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 62.9%, 6.1%, 24.1%, 4.6% and 2.3%, respectively. Compared to others, those with Medicare insurance older (76 vs. 53-60 years), more likely to be female (48% vs. 25-44%), of white race, and with higher comorbidity (all P<0.001). Population from the Medicare cohort had higher in-hospital mortality (5.6%) compared to the others (1.9-3.4%), P<0.001. With Medicare as referent, in-hospital mortality was higher in other {adjusted odds ratio (aOR) 1.15 [95% confidence interval (CI), 1.11-1.19]; P<0.001}, and lower in Medicaid [aOR 0.95 (95% CI, 0.92-0.97); P<0.001], private [aOR 0.77 (95% CI, 0.75-0.78); P<0.001] and uninsured cohorts [aOR 0.97 (95% CI, 0.94-1.00); P=0.06] in a multivariable analysis. Coronary angiography (overall 52% vs. 65-74%; early 15% vs. 22-27%) and PCI (27% vs. 35-44%) were used lesser in the Medicare population. The Medicare population had longer lengths of stay, lowest hospitalization costs and fewer home discharges.Conclusions: Compared to other types of primary payers, NSTEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.

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

“…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.…”

“…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…”

“…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.…”

“…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.…”