DISPARITIES BY INSURANCE STATUS IN QUALITY OF CARE FOR ELDERLY PATIENTS WITH UNSTABLE ANGINA

Context: Treatment disparities for socioeconomically disadvantaged populations have been widely reported, but few studies have sought explanations for these disparities. Objective: To compare the quality of care for patients insured by Medicare alone, Medicare plus Medicaid, or Medicare plus private insurance and investigatemediators for potential disparities. Design, Setting, and Participants: Retrospective, random chart review of 3122 African American or White Medicare patients .65 years of age hospitalized for unstable angina in 22 Alabama hospitals, 1993–1999. Main Outcome Measures: Echocardiogram within 20 minutes of presentation; evaluation by a cardiologist; appropriate anti-platelet therapy within 24 hours of admission and at discharge, heparin for high-risk patients, betablockers during hospitalization, and performance of appropriate coronary angiography. Results: 182 (5.8%) had Medicare only, 433 (13.9%) had Medicare plus Medicaid, and 2507 (80.3%) had Medicare plus private insurance. Medicaid patients were more frequently Black, female, .85 years old, had multiple co-morbidities, or were admitted to hospitals without cardiac catheterization facilities (P,.001). Fewer Medicaid patients were admitted to hospitals with cardiac catheterization capabilities. Even after adjustment for demographics and hospital characteristics, Medicaid patients were less likely to see a cardiologist (odds ratio [OR] .57, 95% confidence interval [CI] .44–.73), receive antiplatelet therapy within 24 hours of admission (OR .66, 95% CI .50–.87), or heparin (OR .71, 95% CI .53–.97). No differences were seen with regard to having an electrocardiogram within 20 minutes of admission. Beta-blockers were used least in the Medicare-only patients, with only 37.7% receiving them (P5.04). Suitable Medicaid patients received coronary angiography less often, even after adjustment for demographics, co-morbidity, and prior revascularization (OR .68, 95% CI .48–.97). However, when adjusted for hospital characteristics, this finding was no longer observed (OR .94, 95% CI .64–1.39). Conclusions: Elderly Medicaid patients appear to receive poorer quality of care. This finding is partially, but not completely, explained by characteristics of the facilities where they are hospitalized