Insurance Status, not Race, is Associated with Mortality After an Acute Cardiovascular Event in Maryland
It is unclear how lack of health insurance or otherwise being underinsured contributes to observed racial disparities in health outcomes related to cardiovascular disease.
To determine the relative risk of death associated with insurance and race after hospital admission for an acute cardiovascular event.
Prospective cohort study in three hospitals in Maryland representing different demographics between 1993 and 2007.
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.
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.
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]).
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 WORDShealth disparities insurance coverage socioeconomic status race cardiovascular disease
- 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.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
- 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
- 24.Iezzoni L, ed. Risk adjustment for measuring healthcare outcomes. 3rd ed. Chicago: Health administration press; 2003.Google Scholar
- 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
- 32.Klein JP, Moeschberger ML. Survival Analysis: Techniques for Censored and Truncated Data 2nd edition. New York, NY: Springer; 2003.Google Scholar
- 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