Financial Barriers Impede Care After Acute MI

NEW HAVEN, Conn., March 13 -- Patients who could not afford health-care services or medications after an acute myocardial infarction had a worse recovery, more angina, and an increased rate of re-hospitalization, researchers reported.

About one in five acute MI patients reported having financial barriers to health care services, Harlan Krumholz, M.D., of Yale, and colleagues, reported in the March 14 issue of the Journal of the American Medical Association, a theme issue on access to health care.

Furthermore, one in eight patients could not afford medications, even though almost 70% of the patients in the study were insured, although perhaps not adequately, found Dr. Krumholz and colleagues.

In the study that followed 2,498 patients with acute MI from 2003 to 2004, 18.1% reported financial barriers to health care services, while 12.9% had trouble affording their medications, the researchers found.

The patients were enrolled in the Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), a 12-month observational, multicenter U.S. study of patients with acute MI.

The findings were based on self-reported financial barriers to health care services or medications (defined as avoidance due to cost). Health status symptoms were evaluated on the Seattle Angina Questionnaire (SAQ), overall health status function (Short Form-12), and re-hospitalization.

Among those who reported financial barriers to health care services or medication, 68.9% and 68.5% respectively were insured, the researchers reported. Since insurance coverage alone does not eliminate financial barriers to health care, in this study the researchers chose to measure self-reported avoidance of health care due to cost, they said.

At one-year follow-up, only 66.2% of those with financial barriers experienced good-to-excellent quality of life compared with 86.8 % of those without the barrier. As a result the mean SAQ and SF-12 scores remained significantly lower for those with financial barriers (P<0.001).

The unadjusted rate for all-cause re-hospitalization among those with barriers to health-care services was 11.2% higher (49.3% versus 38.1%; adjusted hazard ratio 1.3; CI, 1.1-1.5), while the cardiac re-hospitalization rate increased 8% (25.7% versus 17.7%; adjusted HR, 1.3; CI, 1.0-1.6).

At one-year follow-up, those with financial barriers to medication were 17% more likely to have angina (34.9% versus 17.9%; adjusted odds ratio, 1.55; CI, 1.1-2.2, P<0.001) and a lower SAQ quality-of-life score (74.0 versus 86.1; adjusted mean difference=?7.6; CI, ?10.2 to ?4.9).

For patients with financial barriers to medication, the rate of all-cause re-hospitalization increased 19.2% (57.0% versus 37.8%; risk-adjusted HR, 1.5; CI, 1.2-1.8), while the rate for cardiac re-hospitalization was up 16.4% (33.7% versus 17.3%; adjusted HR, 1.7; CI, 1.3-2.2).

There were substantial differences in the baseline characteristic of those who reported financial barriers to health-care services, the researchers said. These patients were more likely to be younger than 65, female, and nonwhite. Additionally, they were more likely to have less education, no insurance, and to live with less income than their counterparts.

There was concern that the differences in post-acute MI outcomes might have been due to potential differences in in-patient care between the two study populations. However a secondary analysis of in-patient care that controlled for coronary angiography and revascularization, for example, did not change the study's findings, the researchers said.

Issues to be considered in interpreting this study, according to the investigators, include the fact that self-reported financial barriers, although reported at baseline, were not reported at one year.

In addition, the study may not be generalizable to the entire U.S. population, particularly to rural groups. Even though the study included a diverse set of sites, there is significant inter-hospital variability in the type and quality of care delivered by U.S. hospitals, which this study may not have reflected adequately.

In summary, the researchers wrote, "Financial barriers to health care are a common and potent risk factor in the AMI population."

They went on to note that these barriers are prominent even in individuals with health insurance, suggesting underinsurance.

"There is a need to develop approaches that will mitigate this increased risk and address this barrier to care and medications," Dr. Krumholz's team concluded.