Online Appendix for the following JACC article
TITLE: Treatment Differences by Health Insurance Among Outpatients With Coronary
Artery Disease
AUTHORS: Smolderen et al.
------------APPENDIX
Online Table 1 Site Characteristics of Participating Practices. An Overview of State, Urbanized
vs. Rural Area Classification, and Median Income Levels per Household (County Level) ±
Standard Deviation Based on Census Data.
Site ID
State
Urbanized vs. Rural
Median Income per
Area*
Household (County
Level) ± SD in USD†
864123
Alabama
Rural
67,098±2,128
785101
Arizona
Urban
44,366±1,046
541063
California
Rural
61,469±533
191475
Florida
Rural
51,412±496
640287
Illinois
Rural
53,080±388
753452
Illinois
Rural
53,080±388
928167
Illinois
Rural
75,014±912
592981
Indiana
Urban
48,121±1,188
727215
Kansas
Urban
47,529±997
103595
Kentucky
Rural
36,792±2,149
820076
Kentucky
Rural
41,974±2,201
Site ID
State
Urbanized vs. Rural
Median Income per
Area*
Household (County
Level) ± SD in USD†
608289
Maryland
Rural
92,451±1,297
463951
Michigan
Rural
40,590±395
785000
Michigan
Rural
48,145±2,945
814407
Missouri
Urban
45,605±783
787370
North-Carolina
Rural
46,954±2,836
256681
Nebraska
Rural
42,542±2,407
784870
New Jersey
Rural
76,072±1,139
211056
New Mexico
Urban
47,019±2,103
511896
New York
Rural
93,448±1,215
887452
New York
Rural
77,881±1,458
351509
Ohio
Rural
41,786±2,069
890162
Pennsylvania
Urban
47,959±596
675145
South Carolina
Urban
46,974±1,136
784392
Texas
Urban
43,724±1,648
833795
Texas
Urban
70,464±1,083
764600
Virginia
Urban
59,605±1,480
775218
Virginia
Urban
35,955±2,379
688306
Washington
Urban
67,711±735
865663
Washington
Urban
67,711±735
Abbreviations: SD, standard deviation.
*http://www.census.gov/geo/www/ua/ua_natl_100302.txt
†http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
Online Table 2 Overview of Quality-of-Care Indicators for CAD. Adapted from the AHA/ACC Clinical Performance Measures for
Chronic Stable Coronary Artery Disease (18) and Guidelines for the Management of Patients with Unstable Angina/Non ST-Elevation
Myocardial Infarction.(10)
Quality Indicator
Description
Numerator
Denominator
Exclusions
β-Blocker Prescription after
Percentage of CAD
Patients who were
All patients with CAD
Medical reasons: e.g.,
Myocardial Infarction
patients with prior MI
prescribed beta-
≥ 18 years of age with
bradycardia, history of Class IV
who were prescribed
blocker therapy
prior MI
heart failure, history of 2nd or 3rd
beta-blocker therapy.
AV block without permanent
pacemaker
Patient reasons: e.g., economic,
social, and/or religious
ACE-I/ARB Prescription in
Percentage of CAD
Patients who were
All patients with CAD
Medical reasons: e.g.,
CAD with LVSD and/or
patients with diabetes
prescribed ACE-I
≥ 18 years of age who
bradycardia, history of Class IV
diabetes
and/or LVSD who were
or ARB therapy
also have LVSD
heart failure, history of 2nd or 3rd
and/or diabetes
AV block without permanent
prescribed ACE-I or
ARB therapy
pacemaker
Patient reasons: e.g., economic,
social, and/or religious
Lipid Lowering Drugs
Percentage of CAD
Patients who were
All patients with CAD
Not indicated for lipid-lowering
Prescription in CAD
patients who were
prescribed lipid-
≥ 18 years of age
therapy refers to LDL-C <100
prescribed lipid-lowering
lowering therapy
Medical reasons: clinical
therapy (based on current
judgment, LDL-C < 130, etc.
ACC/AHA guidelines)
Patient reasons: e.g., economic,
social, and/or religious
Antiplatelet Therapy
Percentage of CAD
Patients who were
All patients with CAD
Medical reasons: active bleeding
Prescription in CAD
patients who were
prescribed
≥18 years of age
in the previous 6 months which
prescribed antiplatelet
antiplatelet therapy
Thienopyridine Therapy
required hospitalization and/or
therapy (including
transfusion(s), patient on other
aspirin, thienopyridine ,
antiplatelet therapy, etc.
or combination of aspirin
Patient reasons: e.g., economic,
and dipyridamole)
social, and/or religious
Percentage of PCI
Patients who were
All patients who
Medical reasons: increased risk of
Prescription in Patients that
patients with drug eluting
thienopyridine
underwent PCI and
bleeding.
Underwent PCI in the Past
stents who were
therapy
received drug eluting
Patient reasons: e.g., economic,
Year
prescribed thienopyridine
stents ≤ 1 year ago
social, and/or religious
therapy
Abbreviations: CAD, coronary artery disease; MI, myocardial infarction; AV block, atrioventricular block; ACE-I, angiotensin
converting enzyme inhibitor; ARB therapy, angiotensin receptor therapy; LVSD, left ventricular systolic dysfunction; LDL-C, lowdensity lipoprotein-cholesterol; PCI, percutaneous coronary intervention.
Online Table 3 Overview of Treatment Rates for CAD Quality-of-Care Indicators by 4 Insurance Status Categories (No Insurance,
Private Insurance, Public Insurance (Medicare and Non-Medicare Insurance). Treatment rates by health care insurance categories
Related to CAD Medications (18) and the prescription of thienopyridine therapy in patients that underwent PCI with DES in the past
year.(10)
Public Insurance
Quality-of-Care Indicator
β-Blocker therapy after
No Insurance
661/4814 (73.3%)
Medicare
Non-Medicare
Insurance
Insurance
723/4792 (83.8%)
433/5752 (78.0%)
MI
ACE-I/ARB therapy in
Private Insurance
P-Value
4601/37424
<.001
(80.5%)
468/5014 (66.7%)
1028/4177 (69.6%) 574/5465 (68.2%)
4223 (75.5%)
<.001
527/3160 (20.6%)
2432/3130 (96.3%) 1879/4333 (95.2%) 15254/27057
<.001
CAD with LVSD and/or
diabetes*
Lipid Lowering Drugs in
CAD
Antiplatelet therapy in
(94.9%)
1256/4336 (91.0%)
2306/3052 (88.6%) 2026/4076 (90.8%) 13378/28484
<.001
CAD†
(91.3%)
Abbreviations: CAD, coronary artery disease; PCI, percutaneous coronary intervention; DES, drug-eluting stent; MI, myocardial
infarction; ACE-I/ARB, angiotensin converting enzyme inhibitor/angiotensin receptor blocker; LVSD, left ventricular systolic
dysfunction. *LVSD denotes left ventricular ejection fraction ≤40%. †Antiplatelet therapy may include aspirin, thienopyridine, or
combination of aspirin and dipyridamole.
Online Table 4 The Association Between Insurance Status Categories (No Insurance, Public
Insurance [Medicare vs. Non-Medicare] vs. Private Insurance) and Treatment Rates for CAD
Quality-of-Care Indicators (Including the 4 ACC/AHA Performance Measures Related to CAD
Medications(18) and the Prescription of Thienopyridine in Patients that Underwent PCI with
DES in the Past Year).(10) The site adjusted model results for the association between insurance
status and treatment rates for the quality indicator are represented (Relative Risk [RR], 95%
Confidence Interval [CI]).
Adjustment for Site
Quality Indicator
RR (95% CI)
P-Value
0.97 (0.93-1.01)
.15
Medicare Insurance
1.04 (0.99-1.08)
.11
Non-Medicare Insurance
0.98 (0.94-1.03)
.46
Private Insurance
Reference
β-Blocker therapy after MI
No Insurance
Public Insurance
ACE-I/ARB therapy in CAD with
LVSD and/or diabetes*
No Insurance
0.95 (0.87-1.03)
.18
Medicare Insurance
0.94 (0.90-0.97)
<.001
Non-Medicare Insurance
0.99 (0.93-1.05)
.66
Private Insurance
Reference
Public Insurance
Lipid Lowering Drugs in CAD
Adjustment for Site
Quality Indicator
RR (95% CI)
P-Value
0.97 (0.95-1.00)
.07
Medicare Insurance
1.01 (1.00-1.02)
.040
Non-Medicare Insurance
0.99 (0.98-1.00)
.09
Private Insurance
Reference
No Insurance
Public Insurance
Antiplatelet therapy in CAD†
No Insurance
0.99 (0.96-1.01)
.35
Medicare Insurance
0.97 (0.95-0.99)
.001
Non-Medicare Insurance
1.00 (0.97-1.03)
.86
Private Insurance
Reference
Public Insurance
Thienopyridine therapy in PCI
patients with DES
No Insurance
0.97 (0.85-1.10)
.63
Medicare Insurance
1.06 (1.01-1.11)
.030
Non-Medicare Insurance
0.98 (0.88-1.09)
.74
Private Insurance
Reference
Public Insurance
Abbreviations: CAD, coronary artery disease; PCI, percutaneous coronary intervention; DES,
drug-eluting stent; MI, myocardial infarction; LVSD, left ventricular systolic dysfunction; ACEI/ARB, angiotensin converting enzyme inhibitor/angiotensin receptor blocker. *LVSD denotes
left ventricular ejection fraction ≤40%. †Antiplatelet therapy may include aspirin, thienopyridine,
or combination of aspirin and dipyridamole.