Patients without health insurance more likely to delay seeking care for heart attack

Patients who do not have health care insurance, or those with insurance but financial concerns about accessing health care, are more likely to delay seeking emergency care for a heart attack, according to a study in the April 14 issue of JAMA.

Although health care insurance status has been shown to affect use of preventive screening and chronic care, little is known about how this status affects decisions to seek care during an emergency medical condition, such as an acute myocardial infarction (AMI; heart attack). Also, studies have not examined whether financial concerns from the patient's perspective about accessing medical care in those with health care insurance is associated with prehospital delays, according to background information in the article. "Because prehospital delays are associated with higher AMI morbidity and mortality, demonstrating that patients with no insurance or those with insurance but reporting financial concerns about accessing care are at higher risk for prehospital delays is important because it would suggest that reducing financial barriers to care—perhaps through expansion of benefits or health insurance coverage—could reduce delays and improve outcomes," the authors write.

Kim G. Smolderen, Ph.D., of Tilburg University, Tilburg, the Netherlands, and colleagues examined the association between lack of health insurance and financial concerns about accessing care among those with health insurance and the time from symptom onset to arriving at the hospital. The researchers used a registry of 3,721 AMI patients enrolled between April 2005 and December 2008 at 24 U.S. hospitals. Health insurance status was categorized as insured without financial concerns, insured but have financial concerns about accessing care, and uninsured. Insurance information was determined from medical records while financial concerns among those with health insurance were determined from structured interviews. Prehospital delay times were categorized as 2 hours or less, between 2-6 hours, or greater than 6 hours. These times were adjusted for various demographic, clinical, and social and psychological factors.

Of the 3,721 patients in the study group, 2,294 were insured without financial concerns (61.7 percent), 689 were insured but had financial concerns about accessing care (18.5 percent), and 738 were uninsured (19.8 percent). Among those with insurance reporting financial concerns, 82.8 percent reported having avoided medical care, 55.6 percent reported having avoided taking medications and 12.8 percent reported having had difficulty obtaining health care services due to costs.

Regarding delays in arriving at the hospital, a greater proportion (36.6 percent) of insured patients without financial concerns arrived within 2 hours of symptom onset compared with 33.5 percent of insured patients with financial concerns and 27.5 percent of uninsured patients. "Conversely, a smaller proportion (39.3 percent) of insured patients without financial concerns arrived more than 6 hours from symptom onset compared with 44.6 percent of insured patients with financial concerns and 48.6 percent of uninsured patients," the authors write. After adjustment for various factors, prehospital delays were associated with insured patients with financial concerns and with uninsured patients.

"These findings underscore important consequences from inadequate health care insurance coverage for the substantial number of individuals in the United States experiencing AMIs. The data also suggest that efforts to reduce prehospital delay times may have limited impact without first ensuring that access to health insurance is improved and financial concerns are addressed in patients who seek emergency care," the authors write.

The authors add that it is likely that uninsured patients and insured patients with financial concerns about accessing care not only delayed seeking care for AMI, but also delayed care for other common medical conditions, such as stroke, pneumonia, and appendicitis. "As a result, interventions that broaden and ensure the affordability of health insurance coverage in the United States may reduce times to presentation for all emergent medical conditions."