Financial Barriers to Health Care and Outcomes After Acute Myocardial Infarction

Rahimi, Ali R. MD, MPH
Spertus, John A. MD, MPH
Reid, Kimberly J. MS
Bernheim, Susannah M. MD, MHS
Krumholz, Harlan M. MD, SM

Department of Medicine (Dr Rahimi), Section of Geriatrics, Department of Medicine (Dr Bernheim), Section of Cardiovascular Medicine, and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, and Section of Health Policy and Administration, Department of Epidemiology and Public Health (Dr Krumholz), Yale University School of Medicine, New Haven, Conn; Department of Cardiology, Mid America Heart Institute of St Luke's Hospital, Kansas City, Mo (Dr Spertus and Ms Reid); Department of Cardiology, University of Missouri—Kansas City (Dr Spertus); and the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn (Dr Krumholz).

Corresponding Author: Harlan M. Krumholz, MD, SM, Yale University School of Medicine, 333 Cedar St, PO Box 208088, New Haven, CT 06520-8088 ([email protected]).

Author Contributions: Drs Rahimi and Krumholz had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Rahimi, Bernheim, Krumholz.

Acquisition of data: Reid, Krumholz.

Analysis and interpretation of data: Rahimi, Spertus, Reid, Krumholz.

Drafting of the manuscript: Rahimi, Reid, Bernheim.

Critical revision of the manuscript for important intellectual content: Rahimi, Spertus, Bernheim, Krumholz.

Statistical analysis: Rahimi, Reid.

Obtained funding: Spertus, Krumholz.

Administrative, technical, or material support: Spertus.

Study supervision: Krumholz.

Financial Disclosures: Dr Spertus reported that he has a research grant from Cardiovascular Therapeutics Inc, and was a consultant for that company. Dr Bernheim was a fellow in the Robert Wood Johnson Clinical Scholars Program during the time the work was conducted. Dr Krumholz reported that he was a consultant for Cardiovascular Therapeutics Inc.

Participating Sites:Academic Centers: Harvard-Beth Israel (David Cohen, MD, SM); Yale-New Haven Hospital (Harlan Krumholz, MD, SM); Duke University (Eric Peterson, MD, MSc); Washington University (Richard Bach, MD); University of Alabama (John Canto, MD); University of Colorado (John Rumsfeld, MD, PhD, John Messenger, MD). Inner-City Hospitals: Truman Medical Center (John Spertus, MD, MPH); Grady Health System (Viola Vaccarino, MD, PhD, William Weintraub, MD, Susmita Parashar, MD); Henry Ford Hospital (Jane Jie Cao, MD, MPH); Denver General Hospitals (Edward Havranek, MD, Frederick Masoudi, MD, MSPH). Single-Payer Systems: Palo Alto Veterans Affairs Hospital (Paul Heidenreich, MD, MPH); Denver Veterans Affairs Hospital (John Rumsfeld, MD, PhD); Colorado Kaiser-Permanente (David Magid, MD). Nonuniversity Hospitals: Sentara Health System (John Brush, MD); Meritcare (Walter Radtke, MD); Baptist Healthcare (Gary Collins, MD)*; Swedish Medical Center (Tim Dewhurst, MD)*; Mid America Heart Institute (John Spertus, MD, MPH). *Terminated the study early due to administrative changes in their organizations that prevented sustainable data collection.

Funding/Support: This work was funded in large part by Cardiovascular Therapeutics Inc, Palo Alto, Calif; Cardiovascular Outcomes Inc, Kansas City, Mo; and the National Heart, Lung, and Blood Institute (P50 HL077113).

Role of the Sponsor: Cardiovascular Therapeutics did not play a role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation, review, and approval of the manuscript.

JAMA: The Journal of the American Medical Association 297(10):p 1063-1072, March 14, 2007.

Context

The prevalence and consequences of financial barriers to health care services and medications are not well documented for patients with an acute myocardial infarction (AMI).

Objective

To measure the baseline prevalence of self-reported financial barriers to health care services or medication (as defined by avoidance due to cost) among individuals following AMI and their association with subsequent health care outcomes.

Design, Setting, and Participants

The Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, multicenter US study of patients with AMI over 12 months in 2498 individuals enrolled from January 2003 through June 2004.

Main Outcome Measures

Health status symptoms (Seattle Angina Questionnaire [SAQ]), overall health status function (Short Form-12), and rehospitalization.

Results

The prevalence of self-reported financial barriers to health care services or medication was 18.1% and 12.9%, respectively. Among individuals who reported financial barriers to health care services or medication, 68.9% and 68.5%, respectively, were insured. At 1-year follow-up, individuals with financial barriers to health care services were more likely to have lower SAQ quality-of-life score (77.9 vs 86.2; adjusted mean difference = −4.0; 95% confidence interval [CI], −6.3 to −1.8), and increased rates of all-cause rehospitalization (49.3% vs 38.1%; adjusted hazard ratio [HR], 1.3; 95% CI, 1.1–1.5) and cardiac rehospitalization (25.7% vs 17.7%; adjusted HR, 1.3; 95% CI, 1.0–1.6). At 1-year follow-up, individuals with financial barriers to medication were more likely to have angina (34.9% vs 17.9%; adjusted odds ratio, 1.55; 95% CI, 1.1–2.2), lower SAQ quality-of-life score (74.0 vs 86.1; adjusted mean difference = −7.6; 95% CI, −10.2 to −4.9), and increased rates of all-cause rehospitalization (57.0% vs 37.8%; risk-adjusted HR, 1.5; 95% CI, 1.2–1.8) and cardiac rehospitalization (33.7% vs 17.3%; adjusted HR, 1.7; 95% CI, 1.3–2.2).

Conclusion

Financial barriers to health care services and medications are associated with worse recovery after AMI, manifested as more angina, poorer quality of life, and higher risk of rehospitalization.