European Journal of Cardiovascular Medicine

Cardiovascular diseases (CVD) are the leading cause of death worldwide. According to WHO 32% of all global deaths are due to cardiovascular diseases and more than 75% of these deaths occur in low to middle income countries.1 The prevalence of CVD in India was estimated to be 54.5 million in the year 2016.2 According to the Global Burden of Disease study age-standardized estimates (2010), nearly a quarter (24.8%) of all deaths in India are attributable to CVD.3

Last three decades have witnessed a transformational change in the management strategies of patients with CVD. The era of conservative medical management has been largely replaced by more aggressive early interventional strategies, especially in patients suffering from acute coronary syndrome (ACS). Data from multiple large-scale studies and consequent guideline recommendations from

international cardiac societies favour such approach in order to improve patient outcomes.4-6 With the exponential growth of interventional cardiac procedures, the cost of patient care is ever increasing.7 In India, out-of-pocket expenditure (OOPE) for health has been the major source of healthcare financing. Data from the Indian National Health Account 2017 revealed that approximately 71% of the overall healthcare spending and 32% of in-patient expenditure was met by OOPE, despite the existing public and private health insurance schemes.8 Considering the fact, that majority of the Indian population belongs to poor or lower-middle class category, OOPE puts a large proportion of our population at significant financial risk. It not only imposes an immediate financial burden to the poor households but also pushes many households into a catastrophic poverty trap.9 Significant proportion of our population is unable to avail quality health care, especially interventional procedures, due to infrastructural and economic constraints. To address this issue, Government of India launched the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) SEHAT scheme, one of the largest government-sponsored health insurance schemes. PMJAY SEHAT scheme entitles the bottom 50% of the Indian population to seek free healthcare in secondary and tertiary care hospitals.10 This scheme was launched on 26 December 2020 in Jammu and Kashmir and provides universal coverage to all residents of the union territory. It covers the cost of hospitalization, pre-hospitalization medication, and post hospitalization expenses incurred during the treatment. Most of the interventional cardiac procedures are covered under this scheme and majority of the healthcare facilities across Jammu and Kashmir are empanelled in this scheme. The aim of current study was to analyse the impact of PMJAY SEHAT scheme on the volume and quality of cardiac interventions in Kashmir Valley.

The current study was a retrospective observational study carried out in the Department of Cardiology, Government Medical College, Srinagar, one of the two premier tertiary care hospitals of Jammu and Kashmir. It was a comparative study in which number and types of interventional cardiac procedures performed during three calendar years, before and after the launch of PMJAY SEHAT scheme were analysed and compared. We collected cardiac catheterization laboratory data of three years, after the launch of PMJAY SEHAT scheme, from 1st January 2021 to 31st December 2023. Similarly, data was collected for three calendar years 1st January 2018 to 26th December 2020 before launch of PMJAY SEHAT scheme. Clinical and demographic characteristics of the patients undergoing procedures in each year were retrieved from case records. Number of cardiac interventional procedures including coronary angiography, percutaneous coronary intervention, permanent pacemaker implantation, Cardiac Resynchronization Therapy (CRT-P/CRT-D), Automatic implantable cardioverter-defibrillator (AICD) implantation, electrophysiological studies and radiofrequency ablation therapy (RFA) were analysed for these two time periods. This study was approved by the Institutional Ethics Committee.

Statistical methods

Statistical analysis was performed using SPSS software (version 20.0, SPSS Inc., Chicago, Illinois, USA) and Python. Continuous data were presented as mean ± standard deviation, while categorical data were expressed as numbers and percentages. Student’s t-test was used for the comparative analysis of continuous variables, whereas the chi-square test was applied for categorical variables. A p-value of <0.05 was considered statistically significant. The Python code used for the comparative analysis is provided at the end of this paper.

Baseline characteristics of the study population are described in Table 1.

Table 1: Showing baseline characteristics of patients during pre and post PMJAY scheme

The table presents a comparative analysis of patient characteristics between pre-PMJAY and post-PMJAY periods to assess potential demographic differences following the implementation of the Pradhan Mantri Jan Arogya Yojana (PMJAY). The variables include age, sex distribution, residence, literacy status, and supplemental insurance coverage, with statistical significance determined using appropriate tests. The mean age of patients remained comparable between the two periods, with 63.7 ± 12.4 years in 2018 and 62.9 ± 13.1 years in 2021 (p = 0.06), indicating no significant age-related variation post-PMJAY implementation. In terms of sex distribution, males constituted the majority of patients in both periods, with a slight decline from 71.8% in 2018 to 70.3% in 2021, while the proportion of female patients increased from 28.2% to 29.7%.  However, this change was not statistically significant (p = 0.325), suggesting that the policy had no major impact on gender representation in healthcare access. Regarding residence, the proportion of rural patients increased from 68.2% in 2018 to 70.1% in 2021, while urban patients decreased from 31.8% to 29.9%. Despite this slight shift, the difference was not statistically significant (p = 0.231), implying that rural-urban disparities in healthcare utilization remained largely unchanged. The literacy status of patients showed minimal variation, with the proportion of literate patients decreasing slightly from 66.5% in 2018 to 65.9% in 2021, while illiterate patients increased from 33.5% to 34.1%. This difference was not statistically significant (p = 0.720). Finally, the proportion of patients with supplemental insurance coverage showed a marginal increase from 1.2% in 2018 to 1.5% in 2021. However, this difference was not statistically significant (p = 0.449), suggesting that additional insurance adoption did not change significantly following PMJAY implementation In summary, while minor demographic shifts were observed post-PMJAY, none of the differences reached statistical significance, indicating that patient characteristics, including age, sex, residence, literacy, and insurance coverage, remained relatively stable between the two periods.

Table 2: Comparison of Cardiovascular Procedures before and After PMJAY Implementation (2018–2020 vs. 2021–2023)

The table presents a comparative analysis of the volume of cardiovascular procedures performed before (2018–2020) and after (2021–2023) the implementation of the Pradhan Mantri Jan Arogya Yojana (PMJAY) scheme. The procedures analysed include angiographies, angioplasties, pacemaker implantations, Automated Implantable Cardioverter Defibrillator (AICD), cardiac resynchronization therapy (CRT-P/CRT-D), and electrophysiology studies with radiofrequency ablation (EPS/RFA). Statistical significance was determined to assess changes in procedural volumes across the two periods. A significant increase in angiographies was observed after PMJAY implementation, rising from a total of 1,661 procedures in 2018–2020 to 3,858 procedures in 2021–2023 (p < 0.0001). Similarly, the number of angioplasties increased substantially, from 1,308 in 2018–2020 to 2,103 in 2021–2023 (p < 0.0001), reflecting a greater accessibility to interventional cardiac care. 712 emergency percutaneous coronary interventions among (PCIs) including primary and rescue angioplasties among 789 eligible patients were performed in post PMJAY period as compared to 267 such procedures among 698 eligible patients in the pre PMJAY period (p<0.0001). For pacemaker implantations, the total number of procedures increased from 490 in the pre-PMJAY period to 913 in the post-PMJAY period. However, this difference was not statistically significant (p = 0.215), indicating that the policy may not have significantly influenced the adoption of pacemaker therapy. In contrast, device therapies including AICD/CRT-P/CRT-D implantations showed an exponential increase from 24 procedures in 2020 to 127 in the post-PMJAY period (2021–2023). This increase was statistically significant (p < 0.0001), suggesting improved accessibility to advanced cardiac therapies following the scheme's implementation. Similarly, EPS/RFA procedures demonstrated a sharp rise from 80 procedures in 2018–2020 to 289 procedures in 2021–2023, with a highly significant p-value (<0.0001). This increase highlights a greater utilization of electrophysiological interventions post-PMJAY scheme launch.

The main findings of this study were as follows:

1. After the launch of PMJAY SEHAT scheme we observed significant twofold increase in the overall number of interventional cardiac procedures performed over a three-year period.
2. There was more than 2.5-fold increase in the number of emergency procedures including primary and rescue angioplasties after the launch of PMJAY scheme.
3. The number of advanced and costly cardiac therapies including CRT-P, CRT-D, and AICD device implantations increased by nearly fivefold after the launch of PMJAY scheme.

The field of interventional cardiology has witnessed revolutionary changes over the past three decades. In the present time, there are plethora of lifesaving interventional cardiac therapies which have solid scientific evidence backing them for improving short- and long-term patient outcomes. Many of these therapies come at a significant cost which makes them unaffordable to a large section of our population. In Jammu and Kashmir, the concept of health insurance was not in vogue till a few years back. Multiple factors including lack of awareness, sociocultural background, lack of corporate establishments and religious beliefs could be the possible reasons behind the inadequate health insurance coverage of our population. It’s a well-known fact that health insurance is associated with delivery of more appropriate and timely health care to the patients covered under such schemes.11 Patients with health insurance are more likely to get hospitalized, undergo thorough workup and get more extensively investigated than those who are not insured.11,12 With regards to treatment, patients covered under health insurance are more likely to receive standard of care therapies at an earlier stage as compared to their uninsured counterparts.11-14

Since the launch of the PMJAY SEHAT scheme in December 2020, entire population of Jammu and Kashmir has been universally insured for hospitalization related expenses incurred from most medical illnesses and interventional/surgical procedures. Majority of the interventional cardiac procedures performed in either government or private secondary and tertiary care hospitals since the launch of this scheme have been performed under its cover. This has led to more widespread and appropriate delivery of interventional cardiology care to the patients which was hitherto unaffordable to a significant proportion of our population.15 In the present study we compared the total volume and individual number of various invasive cardiac procedures performed over a three-year period before and after the launch of PMJAY scheme. We observed that there was a significant 103% increase in the overall number interventional procedures performed during (2021-2023) as compared to (2018-2020).

A significant rise in angiographies and angioplasties was observed after PMJAY implementation. Angiographies increased from 1,661 in the pre-PMJAY period to 3,858 in the post-PMJAY period (p < 0.0001), and angioplasties rose from 1,308 to 2,103 (p < 0.0001). These findings suggest that PMJAY facilitated greater access to diagnostic and interventional cardiac procedures, particularly for patients who may have previously faced financial barriers. Given that ischemic heart disease is a leading cause of morbidity and mortality in Kashmir, this increased procedural volume suggests timely diagnosis and treatment, potentially improving patient outcomes. Overall, there was 132% increase in the number of coronary angiographies, 61% increase in the number of coronary angioplasties and 86% growth in the number of pacemaker implantations after PMJAY launch compared to (2018-2020). Some of this growth in the number of interventional procedures could be attributed to the increasing prevalence of cardiovascular disease and growing awareness regarding the management modalities for the same among the general population. However, given the fact that the patients in the comparative periods (2018–2020 vs. 2021–2023) were similar with respect to baseline parameters, including age, sex distribution, residence, literacy status, and supplemental insurance coverage, it strongly indicates that any observed differences in the volume of cardiovascular procedures were most likely attributable to the universal implementation of the PMJAY scheme.

Since the launch of PMJAY scheme, more cardiac patients deserving interventional treatment are being offered such choice and majority of them give consent for such procedures, knowing that they will not have to bear any OOPE for the same. We observed more than 2.5-fold increase in the number of emergency procedures including primary and rescue angioplasties performed on sick patients suffering from acute coronary syndrome (ACS) after the launch of this scheme. Pertinently, only 38.2% patients eligible for such emergency procedures underwent the same in the pre PMJAY period as compared to 90.2% patients in the post PMJAY period. Previously, patients requiring such lifesaving interventions would have to arrange and spend more than Rs. 100,000 on immediate basis. This would make many patients to forgo such procedures and receive suboptimal pharmacological therapy, which translated into higher mortality and morbidity rates in this patient group. We observed that after the launch of PMJAY scheme all eligible patients admitted in our hospital with ACS had undergone coronary angiography and angioplasty wherever indicated as per guidelines. Pertinently, free of cost and timely delivery of these coronary interventions under the PMJAY scheme has ensured better clinical outcomes in this acutely sick patient population.

Many patients with chronic heart failure have very poor clinical outcomes on stand-alone medical therapy. Nearly 50% of these patients die with five years of the diagnosis of heart failure. These mortality rates are worse than most cancers.16 Till recently very little beyond medical therapy could be offered to such patients and most of them would die awaiting cardiac transplantation. In the last couple of decades there have been significant advances in the management of such patients including several advanced high-end device therapies like AICD, CRT-P and CRT-D implantation. These devices have a proven benefit in terms of improving the survival and quality of life of these advanced heart failure patients.17 However, the average cost of these devices ranges from Rs. 300,000 to Rs. 500,000, which would make them unaffordable to a significant proportion of this patient subset. In the present study, we found a highly significant increase in AICD/CRT-P/CRT-D implantations (p < 0.0001), with procedures rising from 24 in pre-PMJAY period to 127 in the post-PMJAY period. This increase suggests that financial support under PMJAY scheme played a crucial role in enhancing access to advanced heart failure therapies. Similarly, EPS/RFA procedures showed a substantial increase from 80 in pre-PMJAY period to 289 in post-PMJAY period (p < 0.0001). This sharp rise in electrophysiological interventions post-PMJAY highlights the improved affordability and availability of specialized cardiac rhythm management procedures. The growing burden of cardiac arrhythmias, coupled with increased referrals and enhanced diagnostic capabilities, may also have contributed to this trend. Evidently, there was a fivefold increase in the number of heart failure patients receiving these sophisticated devices after the launch of PMJAY scheme. Therefore, this scheme has provided a new hope in terms of prolonging the life of this moribund patient population

The implementation of the Pradhan Mantri Jan Arogya Yojana (PMJAY) scheme has had a profound impact on the accessibility and utilization of cardiovascular procedures in Kashmir, as evidenced by the significant increase in procedural volumes observed in this study. The rise in the number of interventions reflects the effectiveness of the scheme in removing financial barriers to healthcare and expanding access to advanced cardiac treatments, particularly for economically disadvantaged populations. With increasing awareness among common masses, it’s expected that in the near future more people shall avail the benefits of this scheme.

1. World Health Organization: WHO Mortality Database. https://www.who.int/ data/data-collection-tools/who-mortality-database (21 October 2021, date last accessed).
2. GBD 2015 Mortality and Causes of Death Collaborators, Wang H, Naghavi M, Allen C, Barber RM, Bhutta ZA, et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1459–1544.
3. Mensah, G.A., Roth, G.A. and Fuster, V., 2019. The global burden of cardiovascular diseases and risk factors: 2020 and beyond. Journal of the American College of Cardiology, 2020;74(20):2529-2532.
4. Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2014 Dec 23;64(24):e139-228.
5. Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). European heart journal. 2021 Apr 7;42(14):1289-367.
6. O'gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, De Lemos JA, et al. ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American college of cardiology. 2013 Jan 29;61(4):e78-140.
7. Kumar A, Siddharth V, Singh SI, Narang R. Cost analysis of treating cardiovascular diseases in a super-specialty hospital. Plos one. 2022 Jan 5;17(1):e0262190.
8. Dilip TR, Nandraj S. National Health Accounts Estimates. Economic and Political Weekly. 2017 Jun 10;52:20-3.
9. Sriram S, Khan MM. Effect of health insurance program for the poor on out-of-pocket inpatient care cost in India: evidence from a nationally representative cross-sectional survey. BMC Health Services Research. 2020 Dec;20(1):1-21.
10. Angell BJ, Prinja S, Gupt A, Jha V, Jan S. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and the path to universal health coverage in India: Overcoming the challenges of stewardship and governance. PLoS medicine. 2019 Mar 7;16(3):e1002759.
11. Escobar ML, Griffin CC, Shaw RP, editors. The impact of health insurance in low-and middle-income countries. Brookings Institution Press; 2011.
12. Erlangga D, Suhrcke M, Ali S, Bloor K. The impact of public health insurance on health care utilisation, financial protection and health status in low-and middle-income countries: A systematic review. PloS one. 2019 Aug 28;14(8):e0219731.
13. Prinja S, Chauhan AS, Karan A, Kaur G, Kumar R. Impact of publicly financed health insurance schemes on healthcare utilization and financial risk protection in India: a systematic review. PloS one. 2017 Feb 2;12(2):e0170996.
14. Wang W, Temsah G, Mallick L. The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda. Health policy and planning. 2017 Apr 1;32(3):366-75.
15. Khan A, Yatoo GH, Mir MS. Impact of Ayushman Bharat Scheme on the Prevalence of Distress Financing and Catastrophic Health Expenditure Among Patients Attending a Tertiary Care Teaching Hospital. Medicine. 2021;1:01-5.
16. Mamas MA, Sperrin M, Watson MC, Coutts A, Wilde K, Burton C, et al. Do patients have worse outcomes in heart failure than in cancer? A primary care‐based cohort study with 10‐year follow‐up in Scotland. European journal of heart failure. 2017 Sep;19(9):1095-104.
17. Boriani G, Berti E, Belotti LM, Biffi M, De Palma R, Malavasi VL, et al. Cardiac device therapy in patients with left ventricular dysfunction and heart failure:‘real‐world’data on long‐term outcomes (mortality, hospitalizations, days alive and out of hospital). European journal of heart failure. 2016 Jun;18(6):693-702.