Early Results of Massachusetts Healthcare Reform on Racial, Ethnic, and Socioeconomic Disparities in Cardiovascular CareCLINICAL PERSPECTIVE
Background—Insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of healthcare reform in Massachusetts on use of coronary revascularization procedures and in-hospital and 1-year mortality by race/ethnicity, education, and sex.
Methods and Results—Using hospital claims data, we compared differences in coronary revascularization rates (coronary artery bypass grafting or percutaneous coronary intervention) and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents aged 21 to 64 years hospitalized with a principal discharge diagnosis of ischemic heart disease before (November 1, 2004, to July 31, 2006) and after (December 1, 2006, to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted logistic regression assessed 24 216 discharges before reform and 20 721 discharges after reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the prereform period. Compared with whites in the postreform period, blacks (odds ratio=0.73; 95% confidence interval, 0.63–0.84) and Hispanics (odds ratio= 0.84; 95% confidence interval, 0.74–0.97) were less likely and Asians (odds ratio=1.29; 95% confidence interval, 1.01–1.65) were more likely to receive coronary revascularization. Patients living in more educated communities, men, and persons with private insurance were more likely to receive coronary revascularization before and after reform. Compared with the prereform period, the adjusted odds of in-hospital mortality were higher in patients living in less-educated communities in the postreform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed before or after reform.
Conclusions—Reducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated preexisting demographic and educational disparities in access to these procedures.
Blacks are disproportionately affected by cardiovascular disease and have worse cardiovascular health outcomes than other racial and ethnic groups in the United States.1 Potential reasons for these differences include differences in cardiovascular disease risk factors, socioeconomic status, chronic stress, suboptimal interactions with healthcare providers, and access to appropriate healthcare.1,2 Nonwhite Americans may also present with more severe cardiovascular disease because of lack of adequate insurance coverage.2 Prior research has demonstrated that blacks are less likely to receive potentially life-saving cardiovascular procedures such as coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).3,4 For example, in the National Registry of Myocardial Infarction, insurance status was positively associated with the receipt of invasive cardiovascular procedures.5
Clinical Perspective on p 2538
In 2009, 50.7 million Americans lacked health insurance, with the highest rates of uninsurance among Hispanic (32.4%) followed by black (21.0%), Asian (17.0%), and white (12.0%) Americans.6,7 In Massachusetts, rates of uninsurance have been lower than national rates but with similar relative differences by race and ethnicity.8 In April 2006, Massachusetts enacted legislation requiring all residents to have health insurance, expanding MassHealth (Medicaid), providing health insurance subsidies based on income, and requiring that employers with >11 employees offer health insurance or pay financial penalties if they fail to do so.9 Emerging data suggest that since health insurance reform was implemented in Massachusetts, significant reductions in rates of uninsurance occurred according to race, sex, and income level from 2002 to 2006 to 2008. Specifically, uninsurance rates declined from 11.1% to 5.1% for men, from 6.2% to 2.0% for women, from 6.9% to 2.4% for whites, from 12.8% to 7.6% for blacks, and from 13.3% to 10.1% for Hispanics; these declines were statistically significant for all groups except blacks.10 There were also statistically significant reductions in prevalent uninsurance according to income level during this period. However, whether the decline in the number of uninsured Massachusetts residents has translated into narrowed disparities in use of cardiovascular procedures and cardiovascular mortality is unknown.
We evaluated the impact of Massachusetts health insurance reform on racial, ethnic, and socioeconomic disparities in cardiovascular care by determining whether, for Massachusetts residents aged 21 to 64 years with a diagnosis of ischemic heart disease (IHD), (1) the rates of in-hospital coronary revascularization procedures (PCI and CABG) have increased for black, Hispanic, and Asian adults relative to white adults from before to after reform; (2) the relative rates of these coronary procedures have increased for adults according to education level and sex from before to after reform; and (3) health insurance reform has been associated with changes in relative in-hospital and 1-year mortality by these sociodemographic factors.
We used data from 4 sources: billing data from Hospital Case-Mix and Charge data sets collected by the Massachusetts Division of Health Care Finance and Policy; clinical registry data for adults undergoing PCI or cardiovascular surgery in all Massachusetts nonfederal acute care hospitals collected by the Massachusetts Data Analysis Center (Mass-DAC)11; 2000 US Census data (US Census Bureau, 2000 Census of Population and Housing, Summary File 3: Technical Documentation, 2002); and information from the Massachusetts Registry of Vital Records and Statistics. The billing data consisted of patient-level diagnostic and procedural information, sociodemographic information, charge data, discharge status, and a unique health identification number that is an encrypted Social Security number. The Mass-DAC data contain detailed clinical data, including patient information linkable to determine vital status after hospital discharge for the subset of patients undergoing either PCI or cardiac surgery. For these patients, detailed clinical information regarding patient risk, cardiovascular history, and presenting symptoms is available at the time of their procedure. The census data included zip code–level high school educational information linkable to the billing data. Institutional review board approval was attained for use of all records.
All Massachusetts residents age 21 to 64 years discharged alive or dead from acute nonfederal Massachusetts hospitals with a principal discharge diagnosis code of IHD (International Classification of Diseases, Ninth Revision codes 410–414) between November 1, 2004, and September 30, 2008, were identified, and International Classification of Diseases, Ninth Revision procedure codes were used to identify CABG (36.10–36.19) or PCI (36.01–36.07) procedures during admission (Table I in the online-only Data Supplement). Non-Massachusetts residents and patients with zip codes that could not be linked to census data were excluded.
Patients were classified by discharge date as prereform (November 1, 2004, to July 31, 2006) or postreform (December 1, 2006 to September 30, 2008). Because Massachusetts Health reform was enacted in April 2006 but not implemented until July 2006, we selected the 22-month period before July 31, 2006, as prereform and a similar time frame after the initiation of the program. This permitted a 4-month period to elapse to minimize misclassification by reform status. We also selected time frames that were similar according to season of the year.
We categorized patients into 5 racial/ethnic groups (non-Hispanic white, non-Hispanic black [black], Hispanic, Asian, and other/missing). Before October 1, 2006, race was coded as white, black, Hispanic, Asian, or other in the Massachusetts billing data. Beginning on October 1, 2006, Hispanic was separated from race in a distinct ethnic category. We coded a patient as Hispanic if Hispanic was coded as “yes”; if Hispanic was coded as “no,” then we coded the patient using 1 of the race options (white, black, Asian, or other/missing) for discharges observed after October 1, 2006. Patients were classified as residing in a low-, medium-, or high-education area on the basis of tertiles determined by the percentage of Massachusetts residents aged ≥25 years graduating from high school across zip codes; if the percentage was <79.6%, the zip code was classified as a low-education area; zip codes with between 79.6% and 88.6% of residents completing high school were classified as medium-education areas; and zip codes with >88.6% of residents aged ≥25 years completing high school were categorized as high-education areas. Thus, we categorized participants by neighborhood-level education attainment. We grouped insurance status as self-pay (uninsured), free care, public (Medicare and Medicaid), or private (commercial insurance and managed care plans).
We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to determine the presence of common conditions related to the use of revascularization strategies and in-hospital mortality. For each discharge, we identified the presence of a history of myocardial infarction (MI), congestive heart failure, previous CABG or PCI, peripheral vascular disease, chronic lung disease, neoplasm, chronic renal insufficiency, diabetes mellitus status, hypertension, hyperlipidemia, current smoking, cardiogenic shock, and gastrointestinal bleeding (Table I in the online-only Data Supplement). Admission type is a state-specific field coded as emergency, urgent, elective, or unknown in the billing data.
The primary outcome was in-hospital use of CABG or PCI in patients discharged with a principal diagnosis of IHD in the prereform and postreform periods. The secondary outcomes were all-cause in-hospital mortality based on discharge status in the Massachusetts hospital billing data for all IHD discharges and 1-year mortality for those undergoing CABG or PCI.
For 1-year mortality, we calculated rates for PCI and CABG patients separately. We linked Mass-DAC data to the Massachusetts Registry of Vital Records and Statistics to determine vital status; we also conducted searches using the Social Security Death Index Interactive Search tool. Risk factors included in the 1-year mortality models were assembled from the Mass-DAC registry and included adjustors utilized in the state’s public reports. For the 1-year mortality models after CABG surgery, risk factors included diabetes mellitus, peripheral vascular disease, prior PCI, ejection fraction <30%, preoperative cardiac status (cardiogenic shock, MI within 6 hours, MI between 7 and 24 hours, MI >1 day), and operative status (urgent, emergent salvage); for 1-year mortality after PCI, risk factors were renal failure, ejection fraction <30%, left main disease, cardiogenic shock, and operative status (emergent salvage).
Continuous and categorical variables are reported as mean±SD and percentage, respectively. Logistic regression models were fitted separately for each outcome (CABG, PCI with or without stenting, in-hospital mortality among IHD patients, and 1-year mortality among PCI or CABG patients) to estimate odds ratios (ORs) for the primary covariates. Models first controlled for race/ethnicity, age, sex, comorbid conditions, and admission type (model 1). For the 1-year mortality models, we used the risk factors from Mass-DAC, eliminating the claims-based billing admission type variable. We next added census-based education, using patients residing in areas where >88.6% of residents are high school graduates as the reference category (model 2). Finally, we added insurance status to determine whether observed disparities were reduced or eliminated (model 3). We fitted models separately to the prereform and postreform periods to permit different relationships between risk factors and outcomes in the 2 time periods. Testing to determine whether race/ethnicity, education, or sex modified the effect of healthcare reform on outcomes was accomplished through the inclusion of interaction terms of the prereform indicator with the respective variables. A positive coefficient of the interaction term implies a higher relative likelihood of the event in the prereform period compared with the postreform period. We combined patients with acute ST-segment elevation MI and non–ST-segment elevation MI because of low event rates.
We also evaluated interactions of race with sex and with education on the primary outcomes, but none of these interactions were statistically significant, and therefore we present ORs from models without these interaction terms. All P values are 2-tailed. Analyses were conducted with the use of SAS version 9.2 (SAS Institute Inc, Cary, NC).
Race/Ethnicity, Education, and Insurance
Between October 1, 2004, and September 30, 2008 (excluding the period between August 1, 2006, and November 30, 2006), 44 937 discharges with the principal diagnosis of IHD were recorded for nonelderly Massachusetts adults (Table 1), including 82.0% white, 4.1% black, 4.8% Hispanic, 1.3% Asian, and 7.8% patients with missing or other race/ethnicity. Women comprised 25.4% of the entire cohort. The mean age at admission was 54.4±7.3 years. Most patients were admitted on an emergent/urgent basis, with black and Hispanic patients more often represented in this category.
Compared with the prereform period, the prevalence of most comorbid conditions increased in the postreform period. Decreasing rates of hypertension, smoking, congestive heart failure, chronic lung disease, chronic renal insufficiency, and emergent/urgent procedures were noted with increasing education level in both time periods (Table 2). Generally, the percentage of blacks and Hispanics decreased, whereas the opposite was true for whites as education categories increased. As expected, insurance rates increased in all sociodemographic categories, with larger increases observed for minority patients (Table 1) and patients residing in less-educated areas (Table 2).
Primary Outcome: Coronary Revascularization
Compared with the prereform period, the likelihood of PCI among patients hospitalized for IHD decreased in the postreform period (27.2% to 22.3%; P<0.001). A similar decline was noted for CABG procedures (6.3% versus 5.8%; before versus after reform, P=0.013).
In the postreform period, no significant changes were noted in racial/ethnic or socioeconomic disparities in use of CABG and PCI that had been observed in the prereform period. After reform, in models that included education, black and Hispanic patients were 27% and 16% less likely, respectively, and Asian patients were 29% more likely to undergo CABG/PCI than white patients (Table 3; CABG or PCI [in model that includes model 1 covariates and education]). Although persons in the other/missing category had a higher likelihood of receiving revascularization procedures before and after reform, the prevalence of risk factors or clinical conditions that would be associated with IHD are similar compared with that in those persons with a defined race/ethnicity of white, black, or Hispanic (Table II in the online-only Data Supplement). Compared with residents living in zip codes with larger proportions of high school graduates, lower-education areas in both periods were associated with a lower likelihood of having CABG/PCI (Table 4). Women were almost half as likely as men to receive CABG/PCI in either period (Table 5). After adjustment for insurance status, no significant reduction or elimination of the differences was observed (Table 6).
Because comorbidities and other factors might influence receipt of CABG/PCI, we also assessed predictors of CABG/PCI. In the prereform period, the significant predictors of decreased likelihood of having coronary revascularization included previous history of CABG/PCI or MI, congestive heart failure history, female sex, chronic lung disease, neoplasm, black race, and low education. Significant predictors of an increased likelihood of receiving CABG/PCI included the presence of hyperlipidemia, diabetes mellitus, smoking, cardiogenic shock, elective admissions, and other/missing race (all P<0.001). Similar factors were noted in the prereform and postreform periods to predict receipt of CABG/PCI.
In terms of statistically significant differences between the prereform and postreform periods, measured with the use of interaction terms, patients living in low-education areas (versus high-education areas), females (versus males), and patients categorized as other/missing race (versus white) were more likely to undergo PCI or CABG in the prereform than in the postreform period (Table III in the online-only Data Supplement).
Secondary Outcomes: In-Hospital Mortality and 1-Year Mortality
The Figure shows the adjusted odds of receipt of CABG/PCI and unadjusted odds of in-hospital mortality based on race/ethnicity, neighborhood-level education, and sex. Before reform, adjusted in-hospital mortality was significantly lower in blacks compared with whites (referent) (black: OR=0.36; 95% confidence interval [CI], 0.14–0.90; Hispanic: OR=0.62; 95% CI, 0.31–1.26; Asian: OR=0.28; 95% CI, 0.03–2.63). After reform, no statistically significant associations were observed by race/ethnicity (black: OR=0.58; 95% CI, 0.26–1.29; Hispanic: OR=1.16; 95% CI, 0.63–2.12; Asian: OR=0.91; 95% CI, 0.35–2.42). In-hospital mortality was higher for women (OR=1.46; 95% CI, 1.07–2.00) than men before reform but not different in the postreform period (OR=1.02; 95% CI, 0.74–1.41). Finally, in both time frames, in-hospital mortality was higher for patients residing in zip codes where <79.6% of residents graduated from high school (low education: before reform, OR=1.53; 95% CI, 1.05–2.24; after reform, OR=1.62; 95% CI, 1.13–2.31) compared with those who lived where >88.6% of residents were high school graduates. However, no statistically significant interaction terms between reform period and sex or between reform period and neighborhood/area education were observed.
In the prereform period, the 1-year post-PCI mortality rate was 2.9%, whereas it was 2.6% in the postreform setting, which was not statistically significant. For CABG, 1-year mortality rates were 2.5% and 2.0% in the prereform and postreform periods, respectively. There were no significant differences in 1-year mortality after PCI or after CABG in the prereform or postreform periods on the basis of sex or socioeconomic status. Relative to private insurance, only those publicly insured were significantly different (OR=2.45; 95% CI, 1.90–3.17) before reform, whereas after reform, both self-pay (OR=5.89; 95% CI, 2.45–14.1) and public (OR=2.32; 95% CI, 1.76–3.07) PCI discharge patients had higher odds of dying relative to the privately insured group.
In April 2006, Massachusetts extended health insurance coverage to many uninsured residents, particularly those in racial/ethnic minority groups and individuals below the federal poverty level.12 Despite expansion of insurance coverage in these underserved groups, our data indicate that the use of coronary revascularization procedures, an important component of cardiovascular care, did not change meaningfully by race, ethnicity, sex, or neighborhood education level. Compared with white patients, black and Hispanic patients had lower adjusted odds of receiving CABG/PCI, whereas Asians were more likely to receive either procedure. These results suggest that the initial implementation of health insurance reform in Massachusetts has not reduced barriers to the receipt of coronary revascularization related to race/ethnicity, sex, and socioeconomic status.
Our data are consistent with previous work documenting significant racial/ethnic, sex, and socioeconomic disparities related to the performance of coronary procedures.13–15 A systematic review of studies related to racial differences in the use of invasive cardiovascular procedures demonstrated that blacks and Hispanics consistently received fewer procedures than whites despite adjustment for comorbidities, whereas studies about receipt of coronary procedures by Asians compared with whites were conflicting.16 Disparities in the performance of invasive coronary procedures by race/ethnicity and sex could relate to patient-, physician-, or system-level factors. Some work has focused on patient and physician decision making regarding cardiovascular procedures based on race. Physician processing of racial/ethnic and socioeconomic information affects clinical decision making in a manner that may contribute to observed disparities in care,17–20 but data about discrimination and cardiac outcome are scant.21 Healthcare system factors not currently addressed by insurance reform such as referral patterns, accessibility, and availability of cardiovascular specialists may play a role in disparities.22
Our findings are timely and important for several reasons. First, our study examines the effect of “a natural experiment,” implementation of a new state law intended to improve access to care and quality of care by enhancing health insurance affordability and coverage. To our knowledge, this is the first US-based study to evaluate the effect of insurance reform on well-established disparities in invasive cardiovascular procedures, an important component of cardiovascular care.
Second, our findings are consistent with other reports demonstrating that elimination of lack of insurance as a financial barrier does not erase racial, ethnic, and socioeconomic disparities in revascularization rates.23,24 This suggests that other determinants of health might be operative such as discrimination or other unmeasured patient- and system-level factors and is consistent with the framework outlined by the Institute of Medicine’s Unequal Treatment report on healthcare disparities.25 Indeed, Zhu et al26 noted that although health coverage improved by 3% from 2006 to 2008, no improvement was noted in disparities in access to primary care doctors or in self-reported health status. These authors and an accompanying editorial suggest that addressing social determinants of health remains a crucial complementary element to insurance coverage.27 For example, despite relative improvement in coverage among minorities and women in particular, underinsurance may still be a prominent issue for these subgroups if insured patients still face substantial out-of-pocket costs for their healthcare. Underinsurance is further compounded by increasing healthcare costs and higher relative rates of inability to meet basic expenses, factors likely compounded by the ongoing economic recession, which has more severely affected blacks and Hispanics, who have roughly double the unemployment rates of whites. Indeed, data from Clark et al10 indicate that although affordability of care improved in the postreform period compared with the prereform setting, reductions that were previously noted in the numbers of adults with medical debt vanished by the fall of 2009. Additionally, little is known about patient refusal of procedures or adherence to recommended medical therapies by race/ethnicity, sex, or socioeconomic status. Moreover, the threshold for intervention might be higher in underserved groups in general compared with potential overuse in whites, a factor that does not entirely explain observed race/ethnic disparities in revascularization rates.28,29
Third, no change in the disparity in procedure rates by sex was observed despite gains in health insurance coverage (97.1% of women) and having a usual source of care (92.8% of women), as well as a 5.7% decrease in overall unmet need for care among women in Massachusetts from 2006 to 2009.30 The lack of narrowing of the sex disparity might relate to a number of factors including differences in disease presentation by sex and higher out-of-pocket expenses for healthcare in women, a group that typically has lower wages and greater health needs than men in general. Previous work about sex disparities in CABG and PCI performance has been mixed, with some data showing minimal sex disparity in the performance of coronary angiography4 and other work indicating opposite findings.31
Fourth, our finding that blacks had lower in-hospital mortality before reform than other racial groups is consistent with some32 but not all studies after coronary revascularization.33 Moreover, because black patients tend to have more comorbidities, suggesting greater severity of illness on presentation, they are probably more apt to have more clinically appropriate procedures and thus derive greater short-term benefit from coronary revascularization. Another possibility is that the sickest of black patients are not offered intervention, thereby removing this group from the population undergoing coronary revascularization, a procedure that in the short term likely increases the mortality risk of extremely sick patients. In this study, 1-year mortality did not differ significantly by demographic characteristics or insurance type in the prereform compared with the postreform period, a finding that is inconsistent with other work demonstrating higher long-term mortality in blacks compared with other racial and ethnic groups.34,35
We also observed higher in-hospital mortality among those patients who lived in geographic areas where residents had lower levels of education compared with those areas where residents had higher levels of education. These results suggest that socioeconomic status, such as neighborhood environment, is a contributor to cardiovascular disease outcome, a factor that can affect presenting patient comorbidities and thus the risk and benefit of revascularization procedures. Certainly, research indicates that persons who reside in neighborhoods of higher socioeconomic status have lower MI and cardiovascular disease mortality rates36 and also indicates that neighborhood deprivation is positively associated with higher odds of coronary artery calcification.37
Fifth, our data are consistent with longstanding observations of a higher likelihood of receiving coronary interventions among persons who are privately insured. Notably, these data indicate no significant differences in receipt of CABG or PCI in the prereform or postreform period among free care, self-pay, or publically insured compared with private insurance. Indeed, utilizing registry data, Chan and colleagues38 found that among 211 254 nonacute PCIs, privately insured patients were significantly more likely than patients on Medicare, patients on other public insurance, or uninsured patients to receive PCI. Similar findings were noted in an analysis of private insurance and Medicaid patients who presented with ST-segment elevation MI in New York from January 2008 to December 2009; compared with private insurance patients, Medicaid enrollees were less likely to be admitted to a PCI-certified hospital and to undergo PCI after control of confounders.39 A majority of evidence demonstrates that private insurance is associated with lower mortality.31–33 For example, data from New York State teaching hospitals demonstrate an independent-relationship 5-fold increase in mortality among the uninsured or Medicaid compared with privately insured patients.40 In our results, we also observed consistently higher mortality after PCI among publically insured patients in both the prereform and postreform periods. These differences may reflect the impact of disability on mortality among nonelderly Medicare beneficiaries and of individual socioeconomic factors among Medicaid enrollees that were not captured by our neighborhood measure of education. We also found significantly increased mortality among self-pay patients in the postreform period; this group included only 209 patients (<2% of the postreform cohort) who may have been particularly disadvantaged (eg, undocumented immigrants) if they were not eligible for any insurance coverage or free care in the postreform period.
Interestingly, we observed lower coronary revascularization rates in the postreform compared with the prereform period. It is possible that healthcare reform in Massachusetts has coincided with a secular trend of reductions in rates of coronary revascularization, particularly CABG procedures from 2001 through 2008.41 Although national trends indicate stability of the PCI rate over time, these investigators note that the need for repeat revascularization after PCI with drug-eluting stents has decreased and may contribute to the decline in CABG procedures. It is also possible that increased use of statin therapy and physician behavior contribute to the decrement in coronary revascularizations after reform.
Limitations of our study merit consideration. Our results are based on observational administrative data that do not permit adjustment of physician- or system-level decisions regarding patient care; moreover, some comorbidities may reflect consequences of care and not conditions present at admission. We cannot adjust for unmeasured confounders such as ability to obtain a specialist appointment that might affect patient referral for cardiovascular procedures; other factors, such as changes in referral patterns that may well have coincided with health insurance reform, could affect the results. We include patient admission status and comorbidities, both factors that are highly relevant in physician clinical decision making. Additionally, the impact of expanded insurance coverage on procedure rates may have been blunted by the relatively high rates of insurance coverage in the prereform period and the preexisting “free care pool” in Massachusetts that covered hospital care for eligible low-income residents who were uninsured during this period before insurance coverage expanded. We did not have information on patient anatomy based on angiography, but a majority of procedures in our analysis were deemed emergent/urgent, thereby reducing the effect of inappropriate procedures on our findings.
Demographic characteristics such as race/ethnicity could have been self-reported or assigned on the basis of phenotypic characteristics, which could result in race/ethnic misclassification. A new state regulation implemented in April 2007 requires Massachusetts hospitals to collect self-reported race/ethnicity from patients. This regulation may have increased the accuracy of race/ethnicity data during the postreform period.42 Because our analysis involved only Massachusetts, it is unclear whether our findings are generalizable to the US population. Nonetheless, several key points are noteworthy. First, the race/ethnic and socioeconomic disparities we observed parallel findings from other US databases about this topic, even the observation that the disparity related to CABG is greater than that related to PCI in blacks and women. Second, observations related to health insurance reform in Massachusetts may serve as a harbinger for what might occur nationwide with the federal Patient Protection and Affordable Care Act of 2010. Finally, although we presented the data for the other/missing category, we are unable to make comparative assessments with the other race/ethnicity categories except to note that the associated comorbidities and magnitude of results are not similar to those found in blacks and Hispanics.
In summary, although near-universal insurance has been achieved in Massachusetts, disparities in the performance of coronary revascularization procedures persist according to certain demographic characteristics. Our findings support previous work in the Veterans Affairs health system and others that show a limited effect of insurance status on coronary procedure performance. In addition, because the change in the number of persons who were uninsured in Massachusetts before reform compared with after reform was relatively small among adults hospitalized for coronary heart disease, we may not have observed an effect. Nonetheless, our results underscore the need for continued work that focuses on residual factors related to health disparities and implementation of interventions aimed at assessing and addressing specific needs of vulnerable subgroups as part of the healthcare reform process.
This article is dedicated to the memory of Caroline Cecilia Albert (March 1920 to September 2010). We thank Katya Zelevinsky and Robert Wolf for programming assistance, Matthew Cioffi for data management, and Caroline Wood for administrative assistance. We gratefully acknowledge the Division of Health Care Finance and Policy of the Commonwealth of Massachusetts for providing the Hospital Case-Mix and Charge data. Dr Albert was supported by an H. Richard Nesson Fellowship from Brigham and Women’s Hospital. Dr Ayanian was supported by the Health Disparities Research Program of Harvard Catalyst/The Harvard Clinical and Translational Science Center (National Institutes of Health award UL1 RR 025758 and financial contributions from Harvard University and its affiliated academic healthcare centers). T. Silbaugh, A. Lovett, and Dr Normand were supported by a contract with the Department of Public Health of the Commonwealth of Massachusetts (620022A4PRE).
Guest Editor for this article is Mary Cushman, MD.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.113.005231/-/DC1.
- Received July 24, 2013.
- Accepted March 31, 2014.
- © 2014 American Heart Association, Inc.
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Healthcare reform in Massachusetts was implemented in April 2006, and in this analysis we examined the early impact of healthcare reform on racial/ethnic, sex, and neighborhood educational level disparities in the receipt of coronary revascularizations (percutaneous coronary angioplasty or coronary artery bypass grafting). Utilizing merged state data sets, among patients hospitalized at nonfederal acute care hospitals, blacks and Hispanics were 30% and 16%, respectively, less likely than whites to receive coronary revascularization after healthcare reform, a finding that is consistent with the prereform period. By contrast, persons living in neighborhoods with higher educational attainment and Asians were more likely to undergo revascularization than patients from relatively lower neighborhood education attainment environments and whites after healthcare reform. Women were 50% less likely to undergo revascularization than men, and privately insured patients were more likely to receive revascularization in both time frames. No differences in 1-year mortality were observed in any of the groups. These data provide early insights into the effect of healthcare reform in Massachusetts on important sociodemographic cardiovascular healthcare disparities, suggesting that reducing insurance barriers to receipt of coronary revascularization has not yet eliminated preexisting differences.