Abstract 140 Poster Session III, Monday, 5/3 (poster 139)

Within a population based study of congenital cardiovascular malformations comprising all cases in the Maryland, District of Columbia, and Northern Virginia from 1981 to 1991, 103 cases of isolated coarctation of the aorta were reviewed. Interviews were obtained with over 90% of the mothers of the cases in the study. Chart reviews of the cases were made to determine the medical and surgical care received, insurance status at registration, and long term health status. Multiple measures of severity were obtained from chart reviews including physiologic measurements by physical examination, echocardiography, cardiac catheterization, presence of malformations, and global measure of severity. Lack of any health insurance is associated with survival and with compliance. Survival is most strongly associated with maternal education and having any health insurance. Cases with no health insurance are 12 times more likely to be non-survivors. 55% of deaths occur prior to definitive surgical treatment. Compliance with follow up care is strongly associated with having any health insurance and with mothers self reported marital status. Children of married mothers are 7.7 times more likely to complete half of anticipated follow up. Children with any health insurance are 15 times more likely to complete half of anticipated follow up. Severity of illness is not associated with compliance with follow up care. In contrast, having private insurance (rather than Medicaid or lacking insurance) is associated with surgical timing and length of stay. Delay of surgery is associated only with having private insurance (rather than public) and with initial global severity of presenting symptoms with R2=.432. Cases with public insurance have surgery more rapidly after diagnosis. Physiologic measures of severity, e. g. left ventricular dysfunction, are not associted with timing of surgery. Length of stay is associated with having public insurance with the publicly insured cases having longer length of stay. Complications of surgery and recurrence of coarctation after initial operation are associated only with physiologic measures of severity and not with insurance status.

In these cases studied because they antedate managed care regulations, insurance status is strongly associated with traditional measures of health outcomes including survival, length of stay, and timing of surgery. If health insurance information had been unavailable in our study, we would conclude that the health outcomes are only associated with initial severity of illness. Compliance with follow up visits is associated with insurance and mother's marital status. Insurance is not a surrogate variable for race, income, parental education, parental occupation, or marital status in this data. Physician decision making appears to include insurance status as a variable; studies of health outcomes must therefore include this information.