Medicaid patients less likely than those with private insurance to receive recommended cardiac care

The study by Dr. James Calvin, lead study author and director of cardiology at Rush University Medical Center, found Medicaid patients were less likely to receive short term medications and to undergo invasive cardiac procedures. They also had higher in-hospital mortality rates and were less likely to receive recommended discharge care. Differences were fewer and smaller for Medicare patients.

The study is published in the November 21st issue of the Annals of Internal Medicine. In addition to Rush, study participants included Duke University Medical Center, New York University School of Medicine, Northwestern University School of Medicine, University of Cincinnati College of Medicine, and the University of North Carolina at Chapel Hill.

Researchers evaluated data from over 37,000 patients younger than 65 years of age and over 59,000 patients 65 years and older at 521 hospitals across the country. All patients had acute coronary syndromes. These symptoms occur when there is insufficient blood supply to heart muscle. If the blockage lasts long enough, the muscle dies causing a heart attack.

The study measured the use of the recommended guidelines of the American College of Cardiology and American Heart Association. Those guidelines include recommended medications within the first 24 hours, medications and dietary advice to control cholesterol levels, counseling to stop smoking, and cardiac rehabilitation programs.

When compared to patients with HMO or private insurance, Medicaid patients were less likely to receive aspirin, beta-blockers, clopidogrel, and lipid-lowering agents. Medicaid patients were also less likely to receive dietary counseling, smoking cessation counseling, and referral for cardiac rehabilitation. Gaps also existed for acute care. Delays were observed for Medicaid patients in the time to first electrocardiogram and in time to cardiac catheterization and revascularization when these procedures were performed.

Medicaid patients had higher in-hospital mortality rates (2.9% vs. 1.2%) and after adjustment, the risk for death was approximately 30% higher in Medicaid patients compared to those with HMOs and private insurances. Mortality rates were not significantly different for Medicare patients.

“It is reassuring to find that the Medicare system for our older Americans appears to be working, but disappointing to find insurance status affects quality of care and clinical outcomes for cardiac patients under the age of 65,” said Calvin.

The study urges more investigation to determine the root cause of these disparities and develop novel strategies for narrowing the gaps in quality. According to Calvin, it's not simply an issue of economic gain.

“On the surface people may conclude that doctors have a bias against poor people. However, it doesn't cost a thing to tell someone to watch the salt in their diet or to quit smoking, which is really good advice to reduce heart problems,” said Calvin. “We need further study to determine if system problems, such as lack of computerized record keeping or not enough nurses contribute to this disparity. Care by a non-cardiologist may also be partly responsible.”

The patients evaluated in the study were from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early implementation of the ACC/AHA guidelines) quality improvement initiative. Data was collected from January 2001 through March of 2005.