Risk of Cardiovascular Events and Death—Does Insurance Matter?
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Many Americans lack health insurance. Despite good evidence that lack of insurance compromises access to care, few prospective studies examine its relationship to health outcomes.
To determine the relationship between insurance and cardiovascular outcomes and the relationship between insurance and selected process measures.
DESIGN AND PARTICIPANTS
We used data from 15,792 participants in the Atherosclerosis Risk in Communities Study, a prospective cohort study. Participants were enrolled in 1987–1989 and returned for follow-up visits every 3 years, for a total of 4 visits.
MAIN OUTCOME MEASURES
We estimated the hazard of myocardial infarction, stroke, and death associated with insurance status using Cox proportional hazard modeling. We used generalized estimating equations to examine the association between insurance status and risk of (1) reporting no routine physical examinations, (2) being unaware of a personal cardiovascular risk condition, and (3) inadequate control of cardiovascular risk conditions.
Persons without insurance had higher rates of stroke (adjusted hazard ratio, 95% CI 1.22–2.22) and death (adjusted hazard ratio 1.26, 95% CI 1.03–1.53), but not myocardial infarction, than those who were insured. The uninsured were less likely to report routine physical examinations (adjusted risk ratio 1.13, 95% CI 1.08–1.18); more likely to be unaware of hypertension (adjusted risk ratio 1.12, 95% CI 1.00–1.25) and hyperlipidemia (adjusted risk ratio 1.11, 95% CI 1.03–1.19); and more likely to have poor blood pressure control (adjusted risk ratio 1.23, 95% CI 1.08–1.39).
Lack of health insurance is associated with increased rates of stroke and death and with less awareness and control of cardiovascular risk conditions. Health insurance may improve cardiovascular risk factor awareness, control and outcomes.
KEY WORDSinsurance cerebrovascular disease cardiovascular disease populations at risk mortality atherosclerosis
This work was supported by grants from the U.S. Department of Health and Human Services, Health Resources and Services Administration [T32-HP14001]; the National Heart Lung Blood Institute at the National Institutes of Health; and the Robert Wood Johnson Harold Amos Medical Faculty Development Program and was previously presented in abstract form at the national meetings of the Society for General Internal Medicine (2004) and of the AcademyHealth (2004). The Atherosclerosis Risk in Communities Study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute contracts N01-HC-55015, N01-HC-55016, N01-HC-55018, N01-HC-55019, N01-HC-55020, N01-HC-55021, and N01-HC-55022. The National Heart, Lung, and Blood Institute approved a draft of the manuscript. Angela Fowler-Brown had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors thank the staff and participants of the ARIC study for their important contributions. We also pay tribute to the contributions of Dr. Paul McGovern, who helped conceptualize this study before his untimely death.
Potential Financial Conflicts of Interest
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