April 14, 2010 -- A lack of insurance has been linked to delays in patients going to the emergency room when suffering a heart attack, according to research released Tuesday.
A collaboration of investigators studied more than 3,700 patients who suffered heart attacks and came to 24 medical centers in the United States for care.
While patients who may be suffering a heart attack are advised to get medical care within two hours, doctors found that even many patients with health insurance coverage did not do so, a problem that was even greater among patients without insurance or patients who may have been underinsured.
"The message, even among those patients who are adequately insured, is that patients do delay coming in to the hospital," said Dr. Paul Chan, a cardiologist at St. Luke's Mid America Heart Institute and one of the study's authors. "No matter what your insurance status is, the onset of chest pains and symptoms for heart attack are not to be minimized."
Almost 49 percent of patients without insurance and 45 percent of underinsured patients had delayed getting care for more than six hours after a heart attack began. Just over 39 percent of insured patients waited more than six hours to get care.
Dr. Clyde Yancy, president of the American Heart Association, said there were a number of lessons to be taken from the study.
"Even amongst those that have adequate insurance ... there really was quite poor adherence to presenting to a facility in a timely manner," he said. But while getting in within a two-hour window may have been critical, "Even for those that had the resources, it didn't happen."
Yancy said the results of the study suggest not simply a problem with health care and coverage, but with reaching out to the community to let them know the symptoms of a heart attack and the importance of seeking care.
"That's the job of everyone, but especially the American Heart Association," he said.
But current health care legislation alone will not be enough to make Americans more likely to seek help, Yancy said.
"It's going to take more than just access to care to make these disparities in access to care go away," he said.
People needed to know more about the signs of a heart attack and more about the risk factors for a heart attack, he said.
"Even when we get over the hurdle of access, we still have a lot more that needs to be done," Yancy said.
Many disparities in heart care could be reduced by teaching patients what can be done to avoid heart problems in the first place, he said.
"We really need to bring the burden of disease down," he said, adding that any system would be taxed if patients became increasingly unhealthy.
"Even in those with health insurance, care is not ideal," Yancy said. "We really have a lot of work to do."
Heart Attack Treatment: Reasons for a Wait
While the current study looked at delays in seeking care for a heart attack, it did less to discern the reasons behind that delay or the ultimate cost in health care dollars of waiting to come in.
Yancy noted that for patients concerned about the affordability of their care because of a lack of adequate or any health insurance, the consequences of waiting to seek care may be worse, as they may end up needing further treatment.
"The very thing that is the impediment to coming to a facility promptly now becomes compounded, because they come there late and need more care," he said.
Chan said that while patients in the study who came in later had fewer things done to them in the hospital, their stays were longer. Costs were not examined.
"Most people perceive that emergency care is expensive," said Dr. Angela Gardner, president of the American College of Emergency Physicians. "People will take that chance rather than come to the emergency room in order to avoid a costly visit."
But, she said, patients need to remember that they will be taken care of regardless.
"We would hope people come, without regard for the ability to pay, because that is how we treat them," Gardner said.
But while finances may have been a concern, other factors may have played a role in the delay of seeking care.
Patients without health insurance may have been less likely to have a primary care provider, and may have been less likely to know the signs of a heart attack in the first place.
"It may be a lot more than just being aware that you're uninsured or underinsured," Yancy said.
Chan said that in the end, giving everyone health insurance will not change what was observed in this study.
He said rising health care costs, which were not addressed in the legislation, mean that patients will continue to pay more in the form of higher deductibles and coinsurance, so more patients would have insurance but still be concerned about the cost of going to the hospital.
"Patterns of delay will persist ... unless we adequately address those concerns," Chan said. "I don't think we're done, and I think there's a lot more work to be done."
The lead investigator on the study was Kim Smolderen, a psychologist with Tilburg University in the Netherlands.
She said the Dutch press has been having some difficulty in understanding the study, since the uninsured rate in the Netherlands hovers around 1 percent.
"They wouldn't even think it would be possible that someone here would delay their decision to go to the hospital when feeling symptoms of a heart attack," she said.