Lack of health insurance and financial worries about the cost of care contributed to as much as a six-hour delay in seeking emergency care for a heart attack, according to a first-of-its kind study published April 14 in the Journal of the American Medical Association.

It's the first study to link the impact of not having health insurance to patients' decisions to delay emergency treatment during a heart attack. But perhaps most importantly, the study revealed even those with health insurance delayed emergency care, if they had financial concerns.

The results could impact the continued debate about U.S. health care reform as affordability of care remains a challenge to patients, authors say.

"Having private health care insurance did not guarantee use of health services that were essential for these patients, perhaps because they perceived them as unaffordable in the face of competing financial demands," says study senior author Paul S. Chan, M.D., MSc., cardiologist at Saint Luke's Mid America Heart Institute, in Kansas, City, Mo.

In the study, 49 percent of uninsured patients and 45 percent of insured patients with financial concerns delayed seeking care by more than six hours during a heart attack, compared with only 39 percent of insured patients without financial concerns.

The study was developed by researchers at Saint Luke's and involved collaborators throughout the U.S., including the Mayo Clinic College of Medicine in Rochester, Minn. and the University of Michigan Health System in Ann Arbor, Mich.

More than 1 million people have heart attacks each year in the U.S. Life-saving treatments to open the blocked artery and restore blood flow are most effective if started within one hour of the start of symptoms.

Acting fast on warning signs such as chest discomfort and shortness of breath saves lives and prevents damage to the heart muscle.

"The results suggest that efforts to encourage patients to seek life-saving care in a prompt manner may have limited impact without first ensuring that access to health insurance is improved and financial concerns are addressed among patients who seek emergency care," says first author Kim Smolderen, Ph.D., of the Center of Research on Psychology in Somatic Diseases at Tilburg University, Tilburg the Netherlands.

Researchers used a registry of 3,721 participants enrolled in the Translational Research Investigating Underlying Disparities in Acute Myorcardial Infarction Patients' Health Status (TRIUMPH) study at 24 U.S. hospitals. Nearly 40 percent were uninsured or were insured but reported financial concerns about accessing care.

"The inability to address patients' cost concerns may, in part, explain the failure of previous efforts to reduce pre-hospital delays during heart attack," says Brahmajee K. Nallamothu, M.D., M.P.H., cardiologist at the University of Michigan Cardiovascular Center and associate professor of internal medicine at the U-M Medical School.

What's also unique about the study is that researchers used patient interviews to determine affordability of medical care, rather than administrative data alone.

Because black patients and female patients are more likely to have financial concerns about medical costs despite having insurance coverage or be uninsured, improving health coverage has the potential to reduce racial and gender disparities in heart attack care, according to the study.

Authors say that it's likely that uninsured patients and insured patients with financial concerns about accessing care not only would delay seeking care for heart attacks, but would also delay care for other common conditions such as stroke, pneumonia and appendicitis.

"Ultimately, efforts to reduce pre-hospital delays for heart attacks and other emergency conditions may have limited benefit unless U.S. health care insurance coverage is extended and the affordability of care among those with insurance is improved," Chan says.

Additional authors: John A. Spertus, M.D., M.P.H., Saint Luke's Institute; Harlan Krumholz, M.D., Yale University School of Medicine; Fengming Tang, M.S., Saint Luke's Institute; Joseph S. Ross, M.D., Mount Sinai School of Medicine; Henry H. Ting, M.D., MBA, Mayo Clinic; Karen P. Alexander, M.D., Duke University Medical Center, Durham, N.C., and Saif S. Rathore, M.P.H., Yale University.

Reference: Journal of the American Medical Association, Vol. 303, No. 14, April 14, 2010

Source: University of Michigan Health System