Background: Lack of health insurance may present a barrier to healthcare access for patients with acute coronary syndromes. Among interventional procedures, revascularization plays a critical role in treatment for acute coronary syndromes. A growing body of literature addresses outcome differences after percutaneous coronary intervention (PCI) between those with insurance and those without insurance. The purpose of this paper is to perform a systematic review of the literature examining how lack of health insurance is associated with mortality after percutaneous coronary intervention.
Method: An electronic database literature search was performed using the terms “medically uninsured” and “angioplasty”. Further studies were identified from bibliographies of eligible studies. Full-text articles were reviewed based on eligibility criteria. Excluded studies included those in non-U.S. settings, letters to the editor, review narratives, and those that did not explicitly report insurance status and PCI outcomes. Articles were critically appraised using the GRADE criteria.
Results: Two observational cohort studies were analyzed. Both studies showed significantly greater rates of adjusted mortality after percutaneous coronary intervention for patients without insurance. Both studies had limitations common to those of observational studies. The quality of evidence was ultimately rated as moderate using the GRADE method.
Conclusion: Assessment from two observational studies found that lack of health insurance was an independent risk factor for mortality following percutaneous coronary intervention. While no causal relationship can be drawn from this conclusion, mortality differences are likely associated with insurance-related disparities in healthcare access. Clinicians should consider patient-specific financial barriers, including lack of health insurance, when considering treatment and potential outcomes. Because so many Americans are uninsured and many are expected to remain uninsured, these types of studies have critical implications for healthcare reform.
Keywords: medically uninsured, angioplasty, percutaneous coronary intervention
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