Insurance status and the treatment of myocardial infarction at academic centers

Numerous studies have documented treatment disparities in patients with acute coronary syndromes based on race and gender. Other causes for treatment disparities may exist. Objectives: To determine if insurance status affects quality of care in patients with acute myocardial infarction (AMI) presenting to academic health centers. Methods: The Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospective multicenter registry of patients with chest pain presenting to the emergency department who receive an electrocardiogram, was used as the database (N = 17,737). A subset of patients who were diagnosed as having AMI were selected from the database (n = 936). Patients were classified as having either ST-segment elevation MI (n = 178) or non-ST-segment elevation MI (n = 758). Insurance status, age, race, and gender were extracted as predictor variables. The influence of predictor variables on treatment modality was investigated using logistic regression, adjusted for clustering within sites. Results: The odds of a self-pay patient with ST-segment elevation MI receiving fibrinolytics were 3.23 (95% CI = 1.56 to 6.69) times higher than for other patients. Patients with Medicare coverage were less likely to receive fibrinolytics (odds ratio [OR] 0.35, 95% CI = 0.19 to 0.65) and tended to undergo percutaneous coronary intervention less often (OR 0.60, 95% Cl = 0.36 to 1.01). The odds of a privately insured patient's receiving coronary artery bypass grafting (OR 2.76, 95% Cl = 1.62 to 4.72) or percutaneous coronary intervention (OR 1.47, 95% CI = 1.03 to 2.11) were higher than for other patients. Conclusions: Insurance coverage appears to affect treatment in patients with AMI, with self-pay patients more likely to receive less-expensive therapies and insured patients more likely to receive invasive treatments.