AHA: CAD treatment for uninsured is subpar, but better for HF

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CHICAGO—Uninsured patients are less likely to receive evidence-based medication treatment for coronary artery disease (CAD), but not for heart failure (HF), based on data from the national outpatient cardiac registry PINNACLE, which were presented as a scientific poster at the American Heart Association (AHA) Scientific Sessions this week.

While lack of health insurance affects access to outpatient care, the association between health insurance and receiving evidenced-based treatment among outpatients with CAD and HF is not known, according to study authors.

Within the American College of Cardiology’s Practice Innovation and Clinical Excellence (PINNACLE) program, Kim G. Smolderen, PhD, from St. Luke’s MidAmerica Heart Institute in Kansas City, Mo., and colleagues identified 136,204 cardiac patients with an index outpatient visit from over 26 U.S. practices between Jan. 1, 2009, and Dec. 31, 2009. Using modified Poisson regression, the researchers compared compliance rates for six ACC/AHA performance measures related to CAD and HF medications by patients’ insurance status (insured—94 percent—versus not insured—6 percent).

Uninsured patients with CAD were 4, 7 and 15 percent less likely to receive treatment with beta-blockers, lipid lowering and antiplatelet therapy, respectively, compared with insured patients.

However, much of the disparity in lipid lowering and antiplatelet therapy in CAD patients was explained by controlling for the site and physician providing care. For example, whereas uninsured patients were 15 percent less likely to receive antiplatelet therapy for CAD, there was no difference in antiplatelet therapy after adjustment for site and physician.

In contrast, Smolderen and colleagues found there were no differences by insurance status for treatment with ACE inhibitors or ARBs in CAD or HF or with beta-blocker therapy in HF. Specifically, for HF patients with left ventricular systolic dysfunction, 98 percent of insured patients received beta-blockers, compared with 92 percent of uninsured patients. For ACE inhibitors or ARBs, the difference was only slightly higher for CAD patients, 72 versus 70 percent, with a similar two percentage point difference for HF patients—85 versus 83 percent.

“These disparities were largely explained by the site and physician providing care,” the authors concluded. “Efforts to reduce treatment differences by insurance status among cardiac outpatients will need to focus on improving rates of evidence-based treatment at sites with high proportions of uninsured patients.”