Barriers to Healthcare Access and to Improvements in Health-Related Quality of Life after an Acute Coronary Syndrome (From TRACE-CORE)
Abstract
Little is known about how barriers to healthcare access affect health-related quality of life (HRQOL) after an acute coronary syndrome (ACS). In a large cohort of ACS survivors from six medical centers in Massachusetts and Georgia enrolled between 2011-2013, patients were classified as having any financial barriers, no usual source of care (USOC), or transportation barriers to healthcare based on their questionnaire survey responses. The principal study outcomes included clinically meaningful declines in generic physical and mental HRQOL and in disease-specific HRQOL between 1 and 6 months post-hospital discharge. Adjusted relative risks (aRRs) for declines in HRQOL were calculated using Poisson regression models, controlling for several sociodemographic and clinical factors of prognostic importance. Among 1,053 ACS survivors, 29.0% had a financial barrier, 14.2% had no USOC, and 8.7% had a transportation barrier. Patients with a financial barrier had greater risks of experiencing a decline in generic physical (aRR 1.48, 95% CI: 1.17, 1.86) and mental (aRR 1.36, 95% CI 1.07, 1.75) HRQOL at 6 months. Patients with two or more access barriers had greater risks of decline in generic physical (aRR 1.53, 95% CI 1.20, 1.93) and mental (aRR 1.50, 95% CI 1.17, 1.93) HRQOL compared to those without any healthcare barriers. There was a modest association between lacking a USOC and experiencing a decline in disease-specific HRQOL (aRR 1.46, 95% CI: 0.96, 2.22). Financial and other barriers to healthcare access may be associated with clinically meaningful declines in HRQOL after hospital discharge for an ACS.
INTRODUCTION
The majority of the 1.4 million American adults who annually survive a hospitalization for an acute coronary syndrome (ACS) avoid short-term readmission to the hospital and death.1,2 These individuals, however, tend to have worse health-related quality of life (HRQOL) than the general population,3,4 and many experience subsequent declines in HRQOL after hospital discharge for an ACS.5 Better knowledge about changes in HRQOL after an acute coronary event may be particularly useful for patients who are determining their long-term health goals.6 We know little about the factors that affect HRQOL after an ACS,6 particularly with regards to the impact of healthcare access.7 Barriers to healthcare remain common in the U.S.8,9 and these barriers may lead to poor uptake and adherence to secondary prevention therapies for coronary heart disease that could otherwise improve patient’s HRQOL.10,11 Using data from a longitudinal study of hospital survivors of an ACS,12,13 we examined the association between several healthcare barriers with clinically meaningful changes in HRQOL during the six months after hospital discharge for an ACS.
METHODS
In the prospective Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) cohort study,12,13 trained research assistants (RAs) recruited a total of 2,174 adults who survived their hospitalization for an ACS at 6 medical centers in central Massachusetts and Georgia between April, 2011 and May, 2013. Eligibility criteria included being 21 years of age or older and having a confirmed ACS.14 Trained RAs abstracted data from electronic medical records and conducted a baseline interview, either in-person during the index hospitalization or by telephone within 72 hours of discharge. Patients participated in additional telephone interviews after hospital discharge. This study received approval from the Institutional Review Boards at participating sites.
Participants with complete data on the specific barriers to healthcare, type of ACS, SF-36v2® Health Survey physical (PCS) and mental (MCS) component summary scores, 15 and a Seattle Angina Questionnaire Quality of Life (SAQ QOL)16 score at 1 and 6 months after discharge, and various potentially confounding factors, comprised the analytical sample. As our principal exposure factors, we examined variables in this study that could act as enabling resources for care access.17 These included having adequate financial resources, a usual source of care (USOC), and having transportation for obtaining medical care.
Financial barriers to healthcare included difficulty in affording care and lack of insurance at hospital discharge. At the baseline interview, participants answered 2 yes/no questions: “During the past 12 months, have you had any problems paying medical bills?” and “In the past 12 months, have you avoided obtaining any health care services because of the cost?”18 We categorized patients responding affirmatively to either of these questions and/or lacking insurance as having a financial barrier to healthcare.
During the baseline interview, participants answered the question “Is there a place that you usually go to when you are sick or need advice about your health?” We classified patients who responded no to the first question or listing an emergency room in the second question as having no USOC.8
To assess the presence of transportation-related barriers to medical care, participants answered the following questions during the baseline interview: “Overall, and in terms of transportation, how difficult is it for you to get to your health care appointments?” (no problem at all, not very, somewhat, moderately, or extremely difficult) and “Within the past 12 months, have you missed a medical appointment or been unable to obtain needed health care because of problems with your transportation?”. We classified patients who reported missing care or perceiving moderate to extreme difficulty in getting to their medical appointments as having a transportation barrier to accessing healthcare.
To assess generic HRQOL, participants completed the SF-36v2 Health Survey.15 This instrument yields measures that assess overall physical and mental health, with higher scores indicating better HRQOL. We defined changes of ≥ 3.0 points as clinically meaningful decreases and/or increases in HRQOL.19 To assess disease-specific HRQOL, we used the 3-item quality of life scale from the Seattle Angina Questionnaire (SAQ QOL).16 The SAQ QOL is scored from 0 to 100; higher scores indicate better HRQOL. We defined changes of ≥ 16.0 points as clinically meaningful decreases and/or increases in HRQOL.16
Patient’s self-reported race and ethnicity, level of education, household composition, employment status, and smoking status were obtained during the baseline interview. The ACS was classified as either an ST-segment elevation myocardial infarction (STEMI), non-STEMI, or unstable angina.14 Our trained RAs abstracted data on patients’ pre-existing medical conditions, hospital treatment practices, and we calculated Global Registry of Acute Coronary Events (GRACE) risk scores (2.0).20
During the hospitalization, we asked participants “How confident are you filling out medical forms by yourself?” on a 5-point Likert scale21; we categorized those responding extremely/quite a bit, somewhat, and a little bit/not at all as having high, medium, and low health literacy, respectively. We assessed cognitive status using the Telephone Interview for Cognitive Status (TICS) at 1 month after hospital discharge22. Patients completed the Patient Activation Measure, a measure of patients’ knowledge, skills, and confidence to manage their disease.5
We examined the baseline characteristics of participants according to the presence of a financial, USOC, or transportation-related barrier to healthcare access. We used chi-square and unpaired t-tests to compare differences in the distributions of categorical and continuous variables, respectively, among those with and without specific healthcare barriers. We examined differences in mean HRQOL scores after hospital discharge using paired t-tests.
Using Poisson regression models, we calculated relative risks (RR) and accompanying 95% confidence intervals (95% CIs) for experiencing a clinically meaningful decrease in HRQOL at 6 months according to the presence of individual healthcare barriers. Due to potential selection bias resulting from differential loss to follow-up, we performed our regression analyses using inverse probability weighting.23 We first constructed a regression model that contained the three healthcare barriers together. We then adjusted the models for pre-specified factors and additional covariates if their inclusion changed beta coefficients for the association between at least one barrier to healthcare access and changes in HRQOL by ≥10% and also adjusted for the 1-month HRQOL scores.
RESULTS
The analytical sample consisted of 1,053 of the 2,174 original TRACE-CORE study participants. Compared to included participants, those excluded from the present study were younger, were more likely to belong to a racial or ethnic minority, have less education, be unemployed, and have strained monthly finances. Participants who were excluded from the present study, due primarily to a lack of follow-up information on HRQOL, were also more likely to have previously diagnosed heart failure, be a current smoker, not have undergone a percutaneous coronary intervention during their acute hospitalization, have a longer hospital stay, have worse health literacy, and have impaired cognition than included participants. The prevalence of financial barriers to care (38.4% vs. 29.0%), lack of a USOC (19.3% vs 14.2%), and transportation barriers to healthcare access (14.4% vs. 8.7%) were significantly higher among excluded participants (p<0.001).
In the analytical sample, 305 (29.0%) participants had a financial barrier, 149 (14.2%) lacked a USOC, and 92 (8.7%) had a transportation barrier (Table 1). Compared to those without the healthcare barrier of interest, participants with each barrier tended to be younger, female, of a racial or ethnic minority, unemployed, and have strained monthly finances. The frequencies of chronic lung disease, current smoking status, and mildly to severely impaired cognitive status were higher among those with the specific barriers to healthcare access.
Table 1:
Baseline characteristics of hospital survivors of an acute coronary syndrome according to the presence of specific barriers to healthcare access: TRACE-CORE
| Characteristics | Full Sample (n = 1,053) | Financial Barrier (n = 305) | No Usual Source of Care (n = 149) | Transportation Barrier (n = 92) |
|---|---|---|---|---|
| Age, mean, yrs (SD) | 62.7 (10.8) | 58.2 (9.9) | 57.5 (11.1) | 59.6 (10.0) |
| Women | 33.0% | 41.3% | 27.5% | 44.6% |
| Non-Hispanic White | 80.3% | 68.9% | 63.8% | 63.0% |
| Education | ||||
| Less than high school | 10.6% | 16.1% | 18.1% | 22.8% |
| High school | 29.5% | 35.7% | 40.9 | 29.3% |
| Some college / post-high school | 30.8% | 30.2% | 25.5% | 30.4% |
| College graduate | 29.1% | 18.0% | 15.4% | 17.4% |
| Living Situation | ||||
| With spouse | 52.4% | 42.6% | 35.6% | 26.1% |
| With family (non-spouse) | 14.2% | 21.0% | 22.1% | 28.3% |
| With non-family | 13.3% | 14.1% | 18.8% | 19.6% |
| Alone | 20.0% | 22.3% | 23.5% | 26.1% |
| Employment Status | ||||
| Retired | 42.5% | 26.9% | 20.8% | 32.6% |
| Working | 40.9% | 40.7% | 50.3% | 21.7% |
| Unemployed | 16.6% | 32.5% | 28.9% | 45.7% |
| Finances at End of Month (%) | ||||
| Some left over | 50.7% | 21.0% | 38.3% | 18.5% |
| Just enough to make ends meet | 34.1% | 43.0% | 34.9% | 41.3% |
| Not enough to make ends meet | 15.2% | 36.1% | 26.8% | 40.2% |
| Arthritis | 21.2% | 19.0% | 14.1% | 20.7% |
| Cancer | 12.2% | 11.5% | 11.4% | 13.0% |
| Chronic lung disease | 18.0% | 22.6% | 20.8% | 30.4% |
| Chronic kidney disease | 9.5% | 8.9% | 12.1% | 20.7% |
| Diabetes | 30.9% | 38.0% | 25.5% | 54.3% |
| Heart disease | 50.3% | 56.7% | 48.3% | 68.5% |
| Heart failure | 11.2% | 14.1% | 8.7% | 22.8% |
| Hyperlipidemia | 70.7% | 73.1% | 59.1% | 77.2% |
| Hypertension | 75.0% | 77.4% | 68.5% | 87.0% |
| Peripheral vascular disease | 9.6% | 9.2% | 9.4% | 17.4% |
| Stroke/TIA | 8.4% | 8.9% | 7.4% | 14.1% |
| Smoke | ||||
| Never | 31.1% | 26.9% | 20.8% | 18.5% |
| Former | 49.1% | 42.3% | 43.0% | 45.7% |
| Current | 19.8% | 30.8% | 36.2% | 35.9% |
| Acute coronary syndrome type (%) | ||||
| ST-segment elevation myocardial infarction | 16.0% | 11.5% | 16.1% | 10.9% |
| Non-ST-segment elevation myocardial infarction | 54.9% | 58.4% | 55.7% | 57.6% |
| Unstable angina | 29.2% | 30.2% | 28.2% | 31.5% |
| Reperfusion Therapy (%) | ||||
| PCI | 69.2% | 68.9% | 61.1% | 69.6% |
| CABG | 12.9% | 10.5% | 16.8% | 13.0% |
| No PCI or CABG surgery | 17.9% | 20.7% | 22.1% | 17.4% |
| Length of hospital stay ≥ 3 days | 49.4% | 50.5% | 55.0% | 57.6% |
| GRACE risk score, mean (SD)* | 96.1 (26.5) | 90.0 (25.4) | 89.9 (25.8) | 96.6 (27.0) |
| Health Literacy | ||||
| High | 69.0% | 61.6% | 65.1% | 50.0% |
| Medium | 16.4% | 17.4% | 14.1% | 30.4% |
| Low | 14.5% | 21.0% | 20.8% | 19.6% |
| Cognitive Status | ||||
| Normal | 67.1% | 59.3% | 54.4% | 43.5% |
| Ambiguous | 29.5% | 34.8% | 40.3% | 46.7% |
| Mildly or Severely Impaired | 3.3% | 5.9% | 5.4% | 9.8% |
| Patient Activation Level | ||||
| 1: Disengaged (lowest) | 8.8% | 12.8% | 10.1% | 17.4% |
| 2: Aware | 40.7% | 40.7% | 41.6% | 43.5% |
| 3: Taking Action | 21.2% | 21.0% | 20.8% | 15.2% |
| 4: Maintaining Behaviors | 29.2% | 25.6% | 27.5% | 23.9% |
Abbreviations: TIA, transient ischemic attack; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft
The presence of each of the medical history variables examined was determined on the basis of medical chart review.
Mean PCS scores increased between 1 and 6 months after hospital discharge, from 42.4 to 44.0 points (p<.001), although 25.5% of participants experienced a clinically meaningful decrease in their generic physical HRQOL. Patients with each healthcare barrier had significantly lower mean PCS scores at 1 and 6 months post-discharge compared to their counterparts without such barriers (Table 2). Overall, 31.5% who reported a financial barrier to care, 22.2% who lacked a USOC, and 31.5% who had a transportation barrier to care experienced a clinically meaningful decline in their physical HRQOL. Patients with a financial barrier to care had a significantly higher multivariable adjusted risk of experiencing a clinically meaningful decrease in their physical HRQOL but not those lacking a USOC or having a transportation barrier (Table 2).
Table 2:
Scores and clinically meaningful declines in generic physical health-related quality of life (HRQOL) among survivors of an acute coronary syndrome between 1 and 6 months after hospital discharge: TRACE-CORE
| Mean SF36v2 PCS Scores | Weighted Relative Risks Ratios (95% CI) for Clinically Meaningful Declines in Physical HRQOL | |||||
|---|---|---|---|---|---|---|
| Barrier to Healthcare Access | 1 Month Post Discharge (SD) | 6 Months Post Discharge (SD) | Mean Change (SD) | Experiencing Clinically Meaningful Decline | Adjusted Only for Each Other Healthcare Barrier | Fully Adjusted* |
| Financial Barrier | ||||||
| Yes (n = 305) | 39.2 (10.8) | 40.0 (11.9) | 0.8 (8.7) | 31.5% | 1.35 (1.08, 1.70) | 1.48 (1.17, 1.86) |
| No (n = 748) | 43.7 (9.9) | 45.7 (10.9) | 2.0 (8.5) | 23.0% | Referent | Referent |
| No Usual Source of Care | ||||||
| Yes (n = 149) | 41.1 (10.5) | 42.9 (11.8) | 1.8 (8.4) | 22.2% | 0.85 (0.61, 1.18) | 0.96 (0.70, 1.32) |
| No (n = 904) | 42.6 (10.3) | 44.2 (11.5) | 1.6 (8.6) | 26.0% | Referent | Referent |
| Transportation Barrier | ||||||
| Yes (n = 92) | 38.7 (10.0) | 38.6 (11.5) | −0.1 (8.0) | 31.5% | 1.24 (0.88, 1.74) | 1.08 (0.78, 1.50) |
| No (n = 961) | 42.7 (10.3) | 44.5 (11.4) | 1.8 (8.6) | 24.9% | Referent | Referent |
Note: The SF36v2 PCS (Physical Component Summary) score is calculated so that US general population has a mean of 50 (SD=10), with higher scores indicating better generic physical health-related quality of life. A clinically meaningful decrease was defined as a decline of ≥3.0 points between 1 and 6 months after hospital discharge.
Mean MCS scores increased from 50.9 points at 1 month to 52.6 points at 6 months post-discharge (p<0.001); despite these favorable increases, 24.6% of patients experienced a clinically meaningful decline in MCS scores between these time points (Table 3). Mean MCS scores were significantly lower among participants with each healthcare barrier at 1 and 6 months post discharge (Table 3). Slightly less than one third of participants with a financial barrier, lack of a USOC, or transportation barrier experienced a clinical meaningful decline in their mental HRQOL. Patients with a financial barrier to healthcare had a significantly higher multivariable adjusted risk of a meaningful decline in their mental HRQOL (Table 3).
Table 3:
Scores and clinically meaningful declines in generic mental health-related quality of life (HRQOL) among survivors of an acute coronary syndrome between 1 and 6 months after hospital discharge: TRACE-CORE
| Mean SF36v2 MCS Scores | Weighted Relative Risks Ratios (95% CI) for Clinically Meaningful Declines in Mental HRQOL | |||||
|---|---|---|---|---|---|---|
| Barrier to Healthcare Access | 1 Month Post Discharge (SD) | 6 Months Post Discharge (SD) | Mean Change (SD) | Experiencing Clinically Meaningful Decline | Adjusted Only for Each Other Healthcare Barrier | Fully Adjusted* |
| Financial Barrier | ||||||
| Yes (n = 305) | 47.4 (12.5) | 48.8 (12.4) | 1.4 (10.6) | 30.8% | 1.34 (1.06, 1.69) | 1.36 (1.07, 1.75) |
| No (n = 748) | 52.3 (10.2) | 54.1 (9.8) | 1.8 (9.2) | 22.1% | Referent | Referent |
| No Usual Source of Care | ||||||
| Yes (n = 149) | 47.6 (13.8) | 49.4 (14.0) | 1.8 (11.2) | 28.2% | 1.10 (0.82, 1.48) | 1.12 (0.83, 1.51) |
| No (n = 904) | 51.4 (10.2) | 53.1 (10.5) | 1.7 (9.4) | 24.0% | Referent | Referent |
| Transportation Barrier | ||||||
| Yes (n = 92) | 44.3 (13.0) | 44.4 (13.4) | 0.1 (10.8) | 32.6% | 1.20 (0.84, 1.70) | 1.19 (0.83, 1.71) |
| No (n = 961) | 51.5 (10.3) | 53.3 (10.8) | 1.8 (9.5) | 23.8% | Referent | Referent |
Note: The SF36v2 MCS (Mental Component Summary) score is calculated so that the US general population has a mean of 50 (SD=10), with higher scores indicating better generic mental health-related quality of life. A clinically meaningful decrease was defined as a decline of ≥3.0 points between 1 and 6 months after hospital discharge.
Mean SAQ QOL scores increased from 76.2 to 80.9 points between 1 and 6 months post-discharge (p<0.001). Overall, 12.7% of participants experienced a clinically meaningful decline in their disease-specific HRQOL during the 6 months after hospital discharge (Table 4). Participants with each healthcare barrier had lower mean SAQ QOL scores than patients without such a barrier at 1 and 6 months after discharge. Participants without a USOC had a non-significantly elevated risk of experiencing declines in disease-specific HRQOL over the six months after hospital discharge compared to those with a USOC (Table 4).
Table 4:
Scores and clinically meaningful declines in disease-specific health-related quality of life (HRQOL) among survivors of an acute coronary syndrome between 1 and 6 months after hospital discharge: TRACE-CORE
| Mean SAQ QOL Scores | Weighted Relative Risks Ratios (95% CI) for Clinically Meaningful Declines in Disease-Specific HRQOL | |||||
|---|---|---|---|---|---|---|
| Barrier to Healthcare Access | 1 Month Post Discharge (SD) | 6 Months Post Discharge (SD) | Mean Change (SD) | Experiencing Clinically Meaningful Decline | Adjusted Only for Each Other Healthcare Barrier | Fully Adjusted* |
| Financial Barrier | ||||||
| Yes (n = 305) | 68.0 (25.2) | 73.9 (24.0) | 5.9 (20.9) | 14.1% | 1.01 (0.70, 1.46) | 1.03 (0.71, 1.51) |
| No (n = 748) | 79.5 (20.5) | 83.7 (18.4 | 4.2 (19.3) | 12.2% | Referent | Referent |
| No Usual Source of Care | ||||||
| Yes (n = 149) | 69.3 (24.7) | 73.0 (27.2) | 3.7 (21.3) | 17.5% | 1.69 (1.14, 2.51) | 1.46 (0.96, 2.22) |
| No (n = 904) | 77.3 (22.0) | 82.2 (19.1) | 4.9 (19.5) | 12.0% | Referent | Referent |
| Transportation Barrier | ||||||
| Yes (n = 92) | 64.5 (25.2) | 68.3 (27.4) | 3.8 (24.4) | 16.3% | 1.31 (0.79, 2.17) | 1.14 (0.67, 1.92) |
| No (n = 961) | 77.3 (22.0) | 82.1 (19.5) | 4.8 (19.3) | 12.4% | Referent | Referent |
Note: The Seattle Angina Questionnaire quality of life (SAQ QOL) questionnaire is scored on a scale of 0-100 with higher scores indicating better disease-specific health-related quality of life. A clinically meaningful decrease was defined as a decline of ≥16.0 points between 1 and 6 months after hospital discharge.
Overall, 59.8% of patients had no healthcare barriers, 11.2% had a single barrier, and 29.0% had two or all three barriers. As the number of barriers to healthcare access increased, the proportion of patients with a clinically meaningful decline significantly increased for PCS and MCS (Table 5), but did not increase significantly for SAQ QOL. Patients with two or three healthcare barriers had a significantly higher multivariable adjusted risk of experiencing declines in generic physical and mental HRQOL over the following 6 months (Table 5).
Table 5:
Clinically meaningful declines in health-related quality of life among survivors of an acute coronary syndrome between 1 and 6 months after hospital discharge according to the total number of barriers to healthcare access: TRACE-CORE
| No Barriers (n = 630) | 1 Barrier (n = 118) | 2 or More Barriers (n = 305) | |
|---|---|---|---|
| SF36v2 PCS Scores | |||
| Experiencing Clinically Meaningful Decline (%) | 22.9 | 23.7 | 31.5 |
| Weighted Relative Risks Ratios (95% CI) for Clinically Meaningful Decline | |||
| Unadjusted | Referent | 1.08 (0.75, 1.55) | 1.41 (1.13, 1.77) |
| Adjusted* | Referent | 1.10 (0.76, 1.60) | 1.53 (1.20, 1.93) |
| SF36v2 MCS Scores | |||
| Experiencing Clinically Meaningful Decline (%) | 21.1 | 27.1 | 30.8 |
| Weighted Relative Risks Ratios (95% CI) for Clinically Meaningful Decline | |||
| Unadjusted | Referent | 1.27 (0.90, 1.80) | 1.47 (1.16, 1.86) |
| Adjusted† | Referent | 1.30 (0.91, 1.87) | 1.50 (1.17, 1.93) |
| SAQ QOL Scores | |||
| Experiencing Clinically Meaningful Decline (%) | 11.4 | 16.1 | 14.1 |
| Weighted Relative Risks Ratios (95% CI) for Clinically Meaningful Decline | |||
| Unadjusted | Referent | 1.70 (1.06, 2.73) | 1.27 (0.89, 1.83) |
| Adjusted‡ | Referent | 1.28 (0.81, 2.02) | 1.14 (0.76, 1.70) |
Note: For the SF36v2 PCS and MCS, a clinically meaningful decrease was defined as a decline of ≥3.0 points between 1 and 6 months after hospital discharge. For the Seattle Angina Questionnaire quality of life (SAQ QOL) scale, a clinically meaningful decrease was defined as a decline of ≥16.0 points between 1 and 6 months after hospital discharge.
DISCUSSION
The results of this prospective study found that approximately one-quarter of study participants experienced a clinically meaningful decline in their physical or mental HRQOL over the six months after hospital discharge for an ACS, while about one-eighth experienced a decline in disease-specific HRQOL. Patients with a financial barrier had higher risks of experiencing clinically meaningful declines in physical and mental HRQOL over this period. We found that those with two or more barriers to care also had higher risks of experiencing declines in physical and mental HRQOL. We found a modest association between lacking a USOC and an increased risk of experiencing declines in disease-specific HRQOL.
To our knowledge, this is the first study to identify an association between healthcare access barriers with declines in HRQOL after an ACS. A limited number of studies have examined the relationship between healthcare access and HRQOL at a pre-specified time following hospitalization for an ACS, but did not examine changes in HRQOL over time.18,24 In a large nationwide cohort study of patients who were hospitalized for an acute myocardial infarction (AMI), those reporting avoiding healthcare due to costs had lower mean generic physical and mental HRQOL, and lower SAQ QOL scores, at one year after discharge, compared to those without such a barrier.18 We could not identify any prior studies that examined the relationship between lacking a USOC or having a transportation barrier with HRQOL after an ACS.
Our results suggest that those with financial barriers to care may be more likely to experience declines in their physical HRQOL. Patients with difficulty affording healthcare may be less likely to receive follow-up care and effective medical and lifestyle therapies that would otherwise protect their physical health.25 Alternatively, such patients may unnecessarily limit their physical activities after an ACS because they lack reassurance about their safety from providers. Since exercise may have a protective effect against a recurrent coronary event, financial barriers to healthcare could further adversely affect patient’s long-term prognosis.
Patients reporting a financial barrier to healthcare were more likely to experience a subsequent decline in their generic mental HRQOL. In general, survivors of an ACS have a high risk of developing depression.26 Patients with financial constraints on their healthcare may have difficulty accessing standard therapies for depression and/or be less adherent to prescribed treatment modalities than patients without cost constraints.26 Moreover, the constrained financial resources could cause declines in mental HRQOL. Since secondary prevention treatment may impose substantial out-of-pocket costs,27 patients may have to make considerable financial sacrificeswhich could lead to worries about an increased risk of a recurrent coronary event.28
We failed to find an association between lacking a USOC or having a transportation barrier with experiencing clinically meaningful declines in either physical or mental HRQOL. Many patients lack a USOC due to having good health and/or not perceiving a need to regularly see a doctor.29,30 Our inability to find an association between lacking a USOC at baseline with declines in generic HRQOL could result from not being able to distinguish between patients who could not obtain such care from those who did not believe they needed a USOC. Some patients with a transportation barrier at admission may have been able to receive help from their social contacts or through arrangements by healthcare providers after discharge, thereby attenuating the association between transportation barriers with subsequent declines in HRQOL.
Our results leave open the possibility that actions to improve healthcare access may result in better HRQOL. A contemporary systematic review on interventions and changes in HRQOL after an AMI did not identify any studies that used interventions to improve healthcare access.11 Further research is warranted to more fully understand how enhancing healthcare access among survivors of an ACS may improve their HRQOL and how providers might play an important role in this process.
The strengths of this study include its large sample size and assessment of multiple barriers to healthcare access as well as both generic and disease-specific measures of HRQOL. However, we acknowledge the potential for selection bias due to the fairly high loss to follow-up rate and to observed differences between those with and without further follow-up information on HRQOL. Unmeasured confounders, such as the receipt of social services, treatment practices, or changes in employment status after hospital discharge may have affected the relationship between healthcare barriers and changes in patient’s HRQOL.
In conclusion, given the high prevalence of barriers to healthcare in the U.S., additional research is warranted to finding the best approaches to improve healthcare access among these patients, and perhaps consequentially their health status, through health policy changes and better referral of at-risk patients to support services.
Acknowlegements
The National Institutes of Health (NIH) National Heart, Lung, and Blood Institute (NLBI) supported N.E. (1T32HL120823-01), D.M. (R01HL126911), and R.G. (1R01HL135219-01). C.K. received support from the Patient-Centered Outcomes Research Institute (ME-1310-07682) and the NIH National Center for Advancing Translational Sciences (UL1TR0001453-02). The TRACE-CORE study was funded through NIH NLBI grant U01HL105268.
Funding Sources:
The National Institutes of Health (NIH) National Heart, Lung, and Blood Institute (NLBI) supported N.E. (1T32HL120823-01), D.M. (R01HL126911), and R.G. (1R01HL135219-01). C.K. received support from the Patient-Centered Outcomes Research Institute (ME-1310-07682) and the NIH National Center for Advancing Translational Sciences (UL1TR0001453-02). The TRACE-CORE study was funded through NIH NLBI grant U01HL105268.
Footnotes
Conflicts of Interest:
The authors have no conflicts of interest to disclose