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Insurance Type Influences the Use of Drug-Eluting Stents

Division of Cardiology, Washington Hospital Center, Washington, DC

^_* Reprint requests and correspondence: Dr. Ron Waksman, Washington Hospital Center, 110 Irving Street, Northwest, Suite 4B-1, Washington, DC 20010 (Email: ron.waksman{at}medstar.net).

Objectives: We sought to examine the effect of insurance type upon the likelihood of receiving a drug-eluting stent (DES).

Background: Recent guidelines suggest that consideration of a patient's resources should play a role in decisions to use DES. Previous studies have also documented disparities in both access to care and cardiovascular outcomes according to race, insurance, and socioeconomic status. The effect of insurance status upon the decision to use DES is unclear.

Methods: Patients undergoing percutaneous coronary intervention (PCI) with stenting from April 2003 to June 2009, the so-called DES era, were retrospectively analyzed. Multivariable logistic regression was performed separately for patients <65 years and patients 65 years, with receipt of 1 DES during PCI as the outcome variable of interest. Insurance type was categorized as private, Medicare, Medicaid, and uninsured, based upon the primary insurance at discharge. Data regarding duration of clopidogrel therapy at 1 month, 6 months, and 1 year was also collected.

Results: Among the 12,584 patients who underwent PCI with stenting, 6,157 (48.9%) had private insurance, 5,689 (45.2%) had Medicare, 467 (3.7%) had Medicaid, and 271 (2.2%) were uninsured at the time of hospital discharge. There were no significant differences by insurance type in duration of dual antiplatelet therapy at 1 year. Both multivariable logistic regressions showed that Medicaid patients (odds ratio [OR]: 0.60; 95% confidence interval [CI]: 0.46 to 0.78 for age <65 years; OR: 0.45; 95% CI: 0.24 to 0.85 for age 65 years) and patients without insurance (OR: 0.57; 95% CI: 0.42 to 0.78 for age <65 years; OR: 0.20; 95% CI: 0.05 to 0.86 for age 65 years) were less likely to receive DES.

Conclusions: Insurance status has a significant impact upon the decision to use DES. Efforts to address this disparity should focus on the patient-provider level.

Key Words: access • drug-eluting stent • health care • health insurance • socioeconomic status

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   CI = confidence interval   DES = drug-eluting stent(s)   MI = myocardial infarction   OR = odds ratio   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction

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