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From Rush University Medical Center, Chicago, Illinois; Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina; North Shore University Hospital, Long Island, New York; Northwestern University Hospital, Chicago, Illinois; University of Cincinnati School of Medicine, Cincinnati, Ohio; and the University of North Carolina School of Medicine, Chapel Hill, North Carolina.
Grant Support: CRUSADE is funded by Schering-Plough Corporation. Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals Partnership provides additional funding support. Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, also provided funding for this research.
Potential Financial Conflicts of Interest:Consultancies: M.T. Roe (Schering-Plough, Bristol-Myers Squibb, Sanofi), E.M. Ohman (Savacor, Liposcience, Responsible Biomedical, The Medicines Company, Inovise): Honoraria: J.E. Calvin (Millenium Speaker's Bureau), M.T. Roe (Sanofi, Bristol-Myers Squibb, Schering-Plough); Stock ownership or options (other than mutual funds): E.M. Ohman (Inovise, Savacor, Medtronics Inc.); Grants received: M.T. Roe (Schering-Plough, Bristol-Myers Squibb), W.B. Gibler (Schering-Plough, Bristol-Myers Squibb, Sanofi-Aventis), E.M. Ohman (Bristol-Myers Squibb, Sanofi-Aventis, Schering-Plough, Millenium Pharmaceuticals, Eli Lilly Inc., Berlex).
Requests for Single Reprints: James E. Calvin, MD, Section of Cardiology, Rush University Medical Center, 1653 West Congress Parkway, Room 1021-Jelke SC, Chicago, IL 60612; e-mail, James_Calvin@rush.edu.
Current Author Addresses: Dr. Calvin: Section of Cardiology, Rush University Medical Center, 1653 West Congress Parkway, Room 1021-Jelke SC, Chicago, IL 60612.
Drs. Roe and Peterson: Division of Cardiology, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705.
Ms. Chen and Drs. Mehta and DeLong: Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705.
Dr. Brogan: Department of Emergency Medicine, New York University School of Medicine, North Shore Long Island Jewish Health System, Plainview, NY 11803.
Dr. Fintel: Coronary Care Unit, Northwestern University School of Medicine, Wesley Suite 726, 250 East Superior Street, Chicago, IL 60611.
Dr. Gibler: Department of Emergency Medicine, University of Cincinnati College of Medicine, Mail Location 0769, 231 Albert Sabin Way, Cincinnati, OH 45267-0769.
Dr. Ohman: Division of Cardiology, Duke University Medical Center, Room 7403 Duke Hospital North, Box 3126 DUMC, Durham, NC 27705.
Dr. Smith: Center for Cardiovascular Science and Medicine, The University of North Carolina at Chapel Hill, CB #7075, 6th Floor, Burnett-Womack Building, 99 Manning Drive, Chapel Hill, NC 27599-7075.
Author Contributions: Conception and design: S.C. Smith, J.E. Calvin, M.T. Roe, W.B. Gibler, E.D. Peterson, E.M. Ohman.
Analysis and interpretation of the data: M.T. Roe, A.Y. Chen, E.D. Peterson, E.M. Ohman.
Drafting of the article: J.E. Calvin, R.H. Mehta, E.D. Peterson.
Critical revision of the article for important intellectual content: S.C. Smith, J.E. Calvin, M.T. Roe, R.H. Mehta, G.X. Brogan, E.R. DeLong, D.J. Fintel, W.B. Gibler, E.D. Peterson, E.M. Ohman.
Final approval of the article: S.C. Smith, J.E. Calvin, M.T. Roe, R.H. Mehta, G.X. Brogan, E.R. DeLong, D.J. Fintel, W.B. Gibler, E.D. Peterson, E.M. Ohman.
Provision of study materials or patients: E.D. Peterson.
Statistical expertise: M.T. Roe, A.Y. Chen, E.R. DeLong, E.D. Peterson.
Obtaining of funding: E.D. Peterson, E.M. Ohman.
Administrative, technical, or logistic support: E.D. Peterson, E.M. Ohman.
Collection and assembly of data: E.D. Peterson.
CRUSADE is funded by unrestricted grants from Schering-Plough Corporation and the Bristol-Myers Squibb-Sanofi partnership. The CRUSADE project and database are owned and independently operated by the academic coordinating center at the Duke Clinical Research Institute in Durham, North Carolina. All analyses on the database are conducted independently by Duke Clinical Research Institute.
Y-axes denote the percentage use of medications and procedures, and X-axes denote the proportion of Medicaid patients at participating hospitals. The heparin variable includes both unfractionated and low-molecular-weight heparin. ACE = angiotensin-converting enzyme; CABG = coronary artery bypass graft; GP = glycoprotein; PCI = percutaneous coronary intervention.
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To The Editor: Calvin and colleagues (1) report that patients insured by Medicaid (but not Medicare) were less likely to receive evidence-based care for non-ST-segment elevation acute coronary syndromes compared with patients insured by health maintenance organizations or other private payers. However, these investigators were unable to distinguish whether patients received Medicaid coverage through a managed care program, an important limitation. In 2001, at the time of study enrollment, Medicaid provided health coverage to nearly 34 million Americans, 18.8 million (56%) of whom were enrolled in managed care programs (2). Moreover, 19 states had active Section 1115 waivers to implement statewide mandatory managed care enrollment for Medicaid beneficiaries and 14 states had enrolled 75% or more of their Medicaid beneficiaries in managed care programs (2). Since health maintenance organizations have been shown to favorably select younger and healthier Medicaid beneficiaries for enrollment (3), their study is focused on a selected subset of the Medicaid population. Thus, rather than comparing the average Medicaid beneficiary with the average HMO enrollee, their analysis compared Medicaid beneficiaries with fee-for-service coverage, who are likely to be older and less healthy, with all individuals with private insurance, be it employer-based, purchased individually, or provided by Medicaid. Also, until November 2003, Calvin and colleagues categorized all patients enrolled in either Medicaid or Medicare dichotomously (yes if the patient was enrolled in either) and therefore could not distinguish patients enrolled in Medicaid or Medicare before this time. Patients under the age of 65 enrolled in either Medicaid or Medicare were categorized as Medicaid, whereas those 65 or older were categorized as Medicare. However, from 2000 to 2004, the proportion of non-elderly Medicare beneficiaries has grown steadily to 15% of all Medicare beneficiaries (4). It is not clear what proportion of the 6,999 patients categorized as Medicaid beneficiaries were, in fact, Medicare beneficiaries who were totally or permanently disabled or had end-stage renal disease.
Calvin and colleagues should be commended for their examination of an important and understudied topic: quality of care for Medicaid beneficiaries. However, because of the limitations of their principal independent variable, their results can not inform policy makers and health care professionals in the growing number of states who have enrolled the majority of their Medicaid beneficiaries in managed care programs.
Joseph S. Ross, MD, MHS, firstname.lastname@example.org, Mount Sinai School of Medicine and James J. Peters VA Medical Center, New York, NY 10029
Potential Financial Conflicts of Interest: None
1. Calvin JE, Roe MT, Chen AY, et al. Insurance coverage and care of patients with non-ST-segment elevation acute coronary syndromes. Ann Intern Med. 2006;145(10):739-48.
2. Kaiser Family Foundation. Medicaid and Managed Care. December 2001. Available at: http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13724. Last Accessed December 11, 2006.
3. Hellinger FJ, Wong HS. Selection bias in HMOs: a review of the evidence. Med Care Res Rev. 2000;57(4):405-39.
4. Kaiser Family Foundation. Medicare Chart Book 2005. July 19, 2005. Available at: http://www.kff.org/medicare/7284.cfm. Last Accessed December 11, 2006.
IN RESPONSE: Dr. Ross (1) points out that our recent study (2) on the impact of insurance coverage on care and outcomes of patients with nonST-segment elevation acute coronary syndromes defined insurance status based on the patient's primary insurance provider. The provision of a secondary insurance coverage was not collected prior to 2003. As a result, we cannot distinguish Medicaid patients that were also enrolled in managed care programs or who had dual Medicaid/Medicare coverage. After November 2003, we collected multiple insurer data but grouped patients in a hierarchy based on 1) Managed Care; 2) Medicare, and 3) Medicaid. Thus, Dr Ross is correct in stating that this strategy may have excluded Medicaid patients who had additional managed care insurance. Our Medicaid study population may be slightly sicker or have poorer socioeconomic status than those Medicaid patients covered by managed care. Despite this, our analysis did adjust extensively for baseline demographics, disease severity and co-morbid illnesses. Even after this adjustment, we found significant differences in both the use of evidence-based care medications and in-hospital outcomes among Medicaid patients versus those with managed care insurance. While these results may or may not be generalizable to Medicaid/managed care, they are certainly reflective of the large fraction of Medicaid patients who are not covered by managed care. In our opinion, these findings highlight a sizable under-served patient population and a highly important concern to healthcare providers and policy makers.
James E. Calvin, MD Rush University Medical Center, Chicago Illinos
Matthew T. Roe, MD, MHS Duke Clinical Research Institute Durham, NC
Eric D. Peterson, MD, MPH Duke Clinical Research Institute Durham, NC
Relationship of Insurance Type with the Care of Acute Coronary Syndromes
The summary below is from the full report titled “Insurance Coverage and Care of Patients with Non–ST-Segment Elevation Acute Coronary Syndromes.” It is in the 21 November 2006 issue of Annals of Internal Medicine (volume 145, pages 739-748). The authors are J.E. Calvin, M.T. Roe, A.Y. Chen, R.H. Mehta, G.X. Brogan Jr., E.R. DeLong, D.J. Fintel, W.B. Gibler, E.M. Ohman, S.C. Smith Jr., and E.D. Peterson.
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