Role of Health Insurance Status in Interfacility Transfers of Patients With ST-Elevation Myocardial Infarction

Abstract

Lack of health insurance is associated with inter-facility transfer from emergency departments for several non-emergent conditions, but its association with transfers for ST-elevation myocardial infarction (STEMI), which requires timely definitive care for optimal outcomes, is unknown. Our objective was to determine whether insurance status is a predictor of inter-facility transfer for emergency department visits with STEMI. We analyzed data from the 2006 through 2011 Nationwide Emergency Department Sample examining all emergency department visits for patients age 18 years and older with a diagnosis of STEMI and a disposition of inter-facility transfer or hospitalization at the same institution. For emergency department visits with STEMI, our multivariable logistic regression model included emergency department disposition status (inter-facility transfer vs hospitalization at the same institution) as the primary outcome, and insurance status (none vs. any [including Medicare, Medicaid, and private insurance]) as the primary exposure. We found that among 1,377,827 emergency department STEMI visits, including 249,294 (18.1%) transfers, patients without health insurance (adjusted odds ratio: 1.6, 95% CI: 1.5, 1.7) were more likely to be transferred than those with insurance. Lack of health insurance status was also an independent risk factor for transfer compared to each sub-category of health insurance, including Medicare, Medicaid and private insurance. In conclusion, among patients presenting to United States emergency departments with STEMI, lack of insurance was an independent predictor of inter-facility transfer. In conclusion, because inter-facility transfer is associated with longer delays to definitive STEMI therapy than treatment at the same facility, lack of health insurance may lead to important health disparities among patients with STEMI.

Sex, race, and insurance status differences in hospital treatment and outcomes following out-of-hospital cardiac arrest

“…8,9 They may also be less likely to be accepted in transfer to centers that can provide cardiac catheterization and a higher level of care. 7,24 Providers at centers may also be less willing to perform cardiac catheterization when they know that they will be reimbursed at a lower rate. 25 Similarly, patients without insurance may decline costly procedures or move to DNR status due to financial concerns.…”

“…Insurance status may affect whether a patient is accepted for transfer by a 24/7 PCI center. 7,24 Attempted inter-facility transfer may be declined more often by these groups. Female patients may manifest more atypical symptoms than men preceding OHCA leading to delayed recognition of a cardiac etiology and delayed transfer to a 24/7 PCI center.…”

“…Outcome and treatment disparities with respect to age, 4,5 sex, 4,5 race 5,6 and insurance status 5,7–10 have been suggested for OHCA and acute myocardial infarction. However, these studies do not fully describe disparities in United States patient populations with OHCA.…”

Rural Interfacility Emergency Department Transfers: Framework and Qualitative Analysis

“…1,2 As a result, interfacility transfers, in which a patient is transferred from an ED to another ED or hospital, are becoming a more common pathway to access care, even for time-sensitive emergencies. [3][4][5][6] Rural ED visits to non-Veterans Health Administration (VHA) hospitals rose by more than 50% from 2006 to 2015, and a quarter of the ~4.2% patients who were transferred traveled more than 50 miles, most commonly for cardiovascular conditions. 7,8 Rural patients at VHA EDs and urgent care clinics (UCC) are three times more likely to undergo interfacility transfers than their nonrural counterparts, and the most common reasons are for mental health conditions (34%), followed by cardiovascular conditions (12%; internal VHA data).…”

Breaking down walls: a qualitative evaluation of perceived emergency department delays for patients transferred with ST-elevation myocardial infarction

“…Despite decreasing emergency department (ED) visits for ST-elevation myocardial infarction (STEMI) [ 1 ], nearly 1 in 5 ED visits with STEMI result in transfer to another facility and both the absolute number and rate of inter-facility transfer are increasing [ 2 ]. Timely access to the preferred treatment, primary percutaneous coronary intervention (PCI) is associated with improved outcomes [ 3 ], particularly for transfers [ 4 ].…”