Journal of General Internal Medicine

, Volume 33, Issue 9, pp 1543–1550 | Cite as

Barriers to Healthcare Access and Long-Term Survival After an Acute Coronary Syndrome

  • Nathaniel A. Erskine
  • Molly E. Waring
  • David D. McManus
  • Darleen Lessard
  • Catarina I. Kiefe
  • Robert J. GoldbergEmail author
Original Research



Barriers to healthcare are common in the USA and may result in worse outcomes among hospital survivors of an acute coronary syndrome (ACS).


To examine the relationship between barriers to healthcare and 2-year mortality after hospital discharge for an ACS.


Longitudinal study.


Survivors of an ACS hospitalization were recruited from 6 medical centers in central Massachusetts and Georgia in 2011–2013.


Study participants with a confirmed ACS reported whether they had a financial-related healthcare barrier, no usual source of care, or a transportation-related healthcare barrier around the time of hospital admission.




Cox regression analyses calculated adjusted hazard ratios (aHRs) for 2-year all-cause mortality for the three healthcare barriers while controlling for several demographic, clinical, and psychosocial characteristics.


The mean age of study participants (n = 2008) was 62 years, 33% were women, and 77% were non-Hispanic white. One third of patients reported a financial barrier, 17% lacked a usual source of care, and 12% had a transportation barrier. Five percent (n = 100) died within 2 years after hospital discharge. Compared to patients without these barriers, those lacking a usual source of care and with barriers to transportation experienced significantly higher mortality (aHRs 1.40, 95% CI 1.30 to 1.51 and 1.46, 95% CI 1.13 to 1.89, respectively). Financial barriers were not associated with all-cause mortality (aHR 0.79, 95% CI 0.60 to 1.06).


Observational study with other unmeasured potentially confounding prognostic factors.


Absence of an established usual source of care and inconsistent transportation availability were associated with a higher risk for dying after an ACS. Patients with these barriers to follow-up care may benefit from more intensive follow-up and support.


acute coronary syndrome healthcare barriers prospective study 



We are indebted to the trained study staff at each of our participating study sites as well as members of our Observational Study Monitoring Board.

Funding Sources

The National Institutes of Health (NIH) National Heart, Lung, and Blood Institute (NLBI) supported N.E. (1T32HL120823-01), D.M. (R01HL126911) and R.G. (1R01HL135219-01). C.K. received support from the Patient-Centered Outcomes Research Institute (ME-1310-07682) and the NIH National Center for Advancing Translational Sciences (UL1TR0001453-02). The TRACE-CORE study was funded through NIH NLBI grant U01HL105268.

Compliance with Ethical Standards

Conflict of Interest

The authors of this study have no financial conflicts of interest to disclose.

Supplementary material

11606_2018_4555_MOESM1_ESM.docx (384 kb)
ESM 1 (DOCX 354 kb)


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Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Nathaniel A. Erskine
    • 1
  • Molly E. Waring
    • 1
    • 2
  • David D. McManus
    • 1
    • 3
  • Darleen Lessard
    • 1
  • Catarina I. Kiefe
    • 1
  • Robert J. Goldberg
    • 1
    Email author
  1. 1.Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterUSA
  2. 2.Department of Allied Health Sciences, College of Agriculture, Health and Natural ResourcesUniversity of ConnecticutStorrsUSA
  3. 3.Division of Cardiovascular Medicine, Department of MedicineUniversity of Massachusetts Medical SchoolWorcesterUSA

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