Heart Attack Care Often Delayed for the Poor

MONDAY Sept. 22, 2008 -- Poorer Americans, including those on Medicaid, are more likely to take much longer to get to the hospital when a heart attack strikes compared to more affluent people, a new study finds.

The finding suggests that patients without means may be at a greater risk of missing a critical window for time-sensitive care following a heart attack, the researchers noted.

"It's so important to get to the hospital quickly when a patient feels they are having symptoms of a heart attack," noted study lead author Randi E. Foraker, a doctoral candidate in the department of epidemiology at the University of North Carolina, Chapel Hill. "So it was particularly concerning to us that patients from lower socio-economic status areas, and patients covered by Medicaid insurance, experienced more of a pre-hospital delay in getting to a health facility."

Foraker and her team published their findings in the Sept. 22 issue of the Archives of Internal Medicine.

Their conclusions stem from an analysis of more than 6,700 medical records of men and women who experienced a heart attack between 1993 and 2002. By matching patient addresses to 2000 U.S. census data, the research team was able to establish household income levels as either low (less than $33,533), medium (between $33,533 and $50,031) or high (over $50,032).

Foraker and her colleagues determined that 36 percent of the patients faced a short delay (less than two hours) in reaching their local hospital. Another 42 percent experienced a medium delay of between two and 12 hours, while 22 percent underwent a long delay of between 12 hours and three days.

After accounting for such factors as age, gender, health insurance status, history of diabetes and/or high blood pressure, distance to hospital, and race, the study authors found that Medicaid patients and those living in low-income areas were relatively more likely to experience a long or medium delay in getting to the hospital for heart attack care.

For example, patients residing in lower-income neighborhoods were 46 percent more likely to experience a long rather than a short delay in getting to a hospital after heart attack, the study found. And patients on Medicaid were 87 percent more likely to wait a long time before having their symptoms seen to, the team reported.

Why the disparity based on income? The researchers aren't sure. They noted that one factor -- a lack of health insurance -- didn't seem to affect wait times.

"From a public health standpoint these disparities should be further investigated," said Foraker. "And in the meantime, to reduce these disparities, one of the targets may be to increase the recognition of symptoms of a heart attack. And to promote EMS use throughout the community, so people know to call an ambulance right away when they experience these symptoms."

One expert expressed little surprise at the findings.

"As to why this might be so, it seems to me that there is a sort of mystery component to any relationship between income and delay," said Dr. Marshall Morgan, chief of emergency medicine at the Ronald Reagan UCLA Medical Center in Los Angeles. "Recognizing symptoms is key, and I could suggest that although there has been more of an effort in recent years to educate the public about heart attack symptom recognition, this campaign may have penetrated well among the better-educated and less well among the less well-educated. And, of course, there's no question that economic status and education go together.

"It's also important to note that most ambulances are a public service," Morgan added. "So, while emergency services personnel get paid the same whether transporting a rich person or a poorer person, it might be that certain zip codes have a lower distribution of ambulances than others. Much like certain lower income neighborhoods have fewer schools, poorer roads, and a lower distribution of police. So these types of things might explain some of the income-related difference in service."

Posted: September 2008


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