Journal of General Internal Medicine

, Volume 27, Issue 10, pp 1368–1376

Insurance Status, not Race, is Associated with Mortality After an Acute Cardiovascular Event in Maryland

  • Derek K. Ng
  • Daniel J. Brotman
  • Bryan Lau
  • J. Hunter Young
Original Research

ABSTRACT

BACKGROUND

It is unclear how lack of health insurance or otherwise being underinsured contributes to observed racial disparities in health outcomes related to cardiovascular disease.

OBJECTIVE

To determine the relative risk of death associated with insurance and race after hospital admission for an acute cardiovascular event.

DESIGN

Prospective cohort study in three hospitals in Maryland representing different demographics between 1993 and 2007.

PATIENTS

Patients with an incident admission who were either white or black, and had either private insurance, state-based insurance or were uninsured. 4,908 patients were diagnosed with acute myocardial infarction, 6,759 with coronary atherosclerosis, and 1,293 with stroke.

MAIN MEASURES

Demographic and clinical patient-level data were collected from an administrative billing database and neighborhood household income was collected from the 2000 US Census. The outcome of all-cause mortality was collected from the Social Security Death Master File.

KEY RESULTS

In an analysis adjusted for race, disease severity, location, neighborhood household income among other confounders, being underinsured was associated with an increased risk of death after myocardial infarction (relative hazard, 1.31 [95 % CI: 1.09, 1.59]), coronary atherosclerosis (relative hazard, 1.50 [95 % CI: 1.26, 1.80]) or stroke (relative hazard, 1.25 [95 % CI: 0.91, 1.72]). Black race was not associated with an increased risk of death after myocardial infarction (relative hazard, 1.03 [95 % CI: 0.85, 1.24]), or after stroke (relative hazard, 1.18 [95 % CI: 0.86, 1.61]) and was associated with a decreased risk of death after coronary atherosclerosis (relative hazard, 0.82 [95 % CI: 0.69, 0.98]).

CONCLUSIONS

Race was not associated with an increased risk of death, before or after adjustment. Being underinsured was strongly associated with death among those admitted with myocardial infarction, or a coronary atherosclerosis event. Our results support growing evidence implicating insurance status and socioeconomic factors as important drivers of health disparities, and potentially racial disparities.

KEY WORDS

health disparities insurance coverage socioeconomic status race cardiovascular disease 

Supplementary material

11606_2012_2147_MOESM1_ESM.pdf (114 kb)
ESM 1(PDF 113 kb)

REFERENCES

  1. 1.
    Murray CCJL, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, et al. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Medicine. 2006;3:e260.PubMedCrossRefGoogle Scholar
  2. 2.
    Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment and control of hypertension, 1988-2008. JAMA. 2010;303:2043–50.PubMedCrossRefGoogle Scholar
  3. 3.
    Gu Q, Burt VL, Paulose-Ram R, Yoon S, Gillum RF. High blood pressure and cardiovascular disease mortality risk among US adults: the third National Health and Nutrition Examination Survey and mortality follow-up study. Ann Epidemiol. 2008;18:302–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Barnato AE, Lucas FL, Staiger D, Wennberg DE, Chandra A. Hospital-level racial disparities in acute myocardial infarction treatment and outcomes. Med Care. 2005;43:308–319.PubMedCrossRefGoogle Scholar
  5. 5.
    Budoff MJ, Nasir K, Mao S, et al. Ethnic differences of the presence and severity of coronary atherosclerosis. Atherosclerosis. 2006;187:343–350.PubMedCrossRefGoogle Scholar
  6. 6.
    Kivimäki M, Shipley MJ, Ferrie JE, Singh-Manoux A, Batty GD, Chandola T, Marmot MG, Smith GD. Best-practice interventions to reduce socioeconomic inequalities of coronary heart disease mortality in UK: a prospective occupational cohort study. Lancet. 2008;372:1648–54.PubMedCrossRefGoogle Scholar
  7. 7.
    Thomas AJ, Eberly LE, Davey Smith G, Neaton JD, Stamler J. Race/ethnicity, income, major risk factors, and cardiovascular disease mortality. Am J Public Health. 2005;95:1417–23.PubMedCrossRefGoogle Scholar
  8. 8.
    Davey Smith G, Neaton JD, Wentworth D, Stamler R, Stamler J. Mortality differences between black and white men in the USA: contribution of income and other risk factors among men screened for the MRFIT. MRFIT Research Group. Multiple Risk Factor Intervention Tria. Lancet. 1998;351:934–9.PubMedGoogle Scholar
  9. 9.
    LaVeist TA. Disentangling race and socioeconomic status: a key to understanding health inequalities. J Urban Health. 2005;82(2 Suppl 3):26–34.Google Scholar
  10. 10.
    Navarro V. Race or class versus race and class: mortality differentials in the United States. Lancet. 1990;336:1238–40.PubMedCrossRefGoogle Scholar
  11. 11.
    Groman R, Ginsburg J. American College of Physicians. Racial and ethnic disparities in health care: a position paper of the American College of Physicians. Ann Intern Med. 2004;141:225–32.Google Scholar
  12. 12.
    Hauser TH, Ho KK. Accuracy of on-line databases in determining vital status. J Clin Epidemiol. 2001;54:1267–1270.PubMedCrossRefGoogle Scholar
  13. 13.
    Fakhraei SH. Payments for physician services: an analysis of Maryland Medicaid reimbursement rates. Int J Healthc Tech Manag. 2006;7:129–42.CrossRefGoogle Scholar
  14. 14.
    Petersen KL, Marsland AL, Flory J, Votruba-Drzal E, Muldoon MF, Manuck SB. Community socioeconomic status is associated with circulating interleukin-6 and C-reactive protein. Psychosom Med. 2008;70:646–53.PubMedCrossRefGoogle Scholar
  15. 15.
    Scheffler RM, Brown TT, Syme L, Kawachi I, Tolstykh I, Iribarren C. Community-level social capital and recurrence of acute coronary syndrome. Soc Sci Med. 2008;66:1603–13.PubMedCrossRefGoogle Scholar
  16. 16.
    Rabi DM, Edwards AL, Svenson LW, et al. Association of median household income with burden of coronary artery disease among individuals with diabetes. Circ Cardiovasc Qual Outcomes. 2010;3(1):48–53.PubMedCrossRefGoogle Scholar
  17. 17.
    Reinier K, Thomas E, Andrusiek DL, Aufderheide TP, Brooks SC, Callaway CW, et al. Socioeconomic status and incidence of sudden cardiac arrest. CMAJ. 2011;183:1705–12.PubMedCrossRefGoogle Scholar
  18. 18.
    Guilley E, Herrmann F, Rapin C, et al. Socioeconomic and living conditions are determinants of hip fracture incidence and age occurrence among community-dwelling elderly. Osteoporos Int. 2011;22:647–53.PubMedCrossRefGoogle Scholar
  19. 19.
    Jolly M, Mikolaitis RA, Shakoor N, Fogg LF, Block JA. Education, zip code-based annualized household income, and health outcomes in patients with systemic lupus erythematosus. J Rheumatol. 2010;37:1150–1157.PubMedCrossRefGoogle Scholar
  20. 20.
    Zeng Z. Multiple imputation for missing income data in population-based health surveillance. J Public Health Manag Pract. 2009;15:E12–21.PubMedGoogle Scholar
  21. 21.
    Nur U, Shack LG, Rachet B, Carpenter JR, Coleman MP. Modelling relative survival in the presence of incomplete data: a tutorial. Int J Epidemiol. 2010;39:118–128.PubMedCrossRefGoogle Scholar
  22. 22.
    Shrier I, Kahn SR, Steele RJ. Effect of early physical activity on long-term outcome after venous thrombosis. Clin J Sport Med. 2009;19:487–493.PubMedCrossRefGoogle Scholar
  23. 23.
    Rubin DB. Multiple imputation for nonresponse in surveys. New York: John Wiley & Sons; 1987.CrossRefGoogle Scholar
  24. 24.
    Iezzoni L, ed. Risk adjustment for measuring healthcare outcomes. 3rd ed. Chicago: Health administration press; 2003.Google Scholar
  25. 25.
    Nante N, Messina G, Cecchini M, et al. Sex differences in use of interventional cardiology persist after risk adjustment. J Epidemiol Community Health. 2009;63:203–208.PubMedCrossRefGoogle Scholar
  26. 26.
    Sedman AB, Bahl V, Bunting E, et al. Clinical redesign using all patient refined diagnosis related groups. Pediatrics. 2004;114:965–969.PubMedCrossRefGoogle Scholar
  27. 27.
    Romano PS, Chan BK. Risk-adjusting acute myocardial infarction mortality: are APR–DRGs the right tool? Health Serv Res. 2000;34:1469–1489.PubMedGoogle Scholar
  28. 28.
    Cleves M, Gould W, Gutierrez R, Marchenko Y. An introduction to survival analysis using Stata, 2nd Edition. Stata Press College Station, Texas: 2008.Google Scholar
  29. 29.
    Lash TL, Fink AK. Semi-Automated Sensitivity Analysis to Assess Systematic Errors in Observational Data. Epidemiology. 2003;14:451–458.PubMedGoogle Scholar
  30. 30.
    Phillips CV. Quantifying and Reporting Uncertainty from Systematic Errors. Epidemiology. 2003;14:459–466.PubMedGoogle Scholar
  31. 31.
    Kitahata MM, Gange SJ, Abraham AG, Merriman B, Saag MS, Justice AC, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. 2009;360:1815–26.PubMedCrossRefGoogle Scholar
  32. 32.
    Klein JP, Moeschberger ML. Survival Analysis: Techniques for Censored and Truncated Data 2nd edition. New York, NY: Springer; 2003.Google Scholar
  33. 33.
    Spertus JA, Jones PG, Masoudi FA, Rumsfeld JS, Krumholz HM. Factors associated with racial differences in myocardial infarction outcomes. Ann Intern Med. 2009;150:314–24.PubMedGoogle Scholar
  34. 34.
    Laveist T, Pollack K, Thorpe R Jr, Fesahazion R, Gaskin D. Place, not race: disparities dissipate in southwest Baltimore when blacks and whites live under similar conditions. Health Aff. 2011;30:1880–7.CrossRefGoogle Scholar
  35. 35.
    Fowler-Brown A, Corbie-Smith G, Garrett J, Lurie N. Risk of cardiovascular events and death–does insurance matter? J Gen Intern Med. 2007;22:502–507.PubMedCrossRefGoogle Scholar
  36. 36.
    Bleich SN, Thorpe RJ, Sharif-Harris H, Fesahazion R, Laveist TA. Social context explains race disparities in obesity among women. J Epidemiol Community Health. 2010;64:465–469.PubMedCrossRefGoogle Scholar
  37. 37.
    Borell LN. Diez Roux AV, Rose K, Catellier D, Clark BL, Atherosclerosis risk in communities study: neighborhood characteristics and mortality in the atherosclerosis risk in communities study. Int J Epidemiol. 2004;33:398–407.CrossRefGoogle Scholar
  38. 38.
    Diez Roux AV, Merkin SS, Arnett D, Chambless L, Massing M, Nieto FJ, Sorlie P, Szklo M, Tyroler HA, Watson RL. Community of residence and incidence of coronary heart disease. N Engl J Med. 2001.Google Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Derek K. Ng
    • 1
  • Daniel J. Brotman
    • 2
  • Bryan Lau
    • 1
    • 2
  • J. Hunter Young
    • 1
    • 2
  1. 1.Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  2. 2.Department of MedicineJohns Hopkins Medical InstitutionsBaltimoreUSA

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