RESUMO
BACKGROUND: US adults often overpay for generic prescription medications, which can lead to medication nonadherence that negatively impacts cardiovascular outcomes. As a result, new direct-to-consumer online medication services are growing in popularity nationwide. Amazon recently launched a $5/month direct-to-consumer medication subscription service (Amazon RxPass), but it is unclear how many US adults could save on out-of-pocket drug costs by using this new service. OBJECTIVES: To estimate out-of-pocket savings on generic prescription medications achievable through Amazon's new direct-to-consumer subscription medication service for adults with cardiovascular risk factors and/or conditions. METHODS: Cross-sectional study of adults 18-64 years in the 2019 Medical Expenditure Panel Survey. RESULTS: Of the 25,280,517 (SE ± 934,809) adults aged 18-64 years with cardiovascular risk factors or conditions who were prescribed at least 1 medication available in the Amazon RxPass formulary, only 6.4% (1,624,587 [SE ± 68,571]) would achieve savings. Among those achieving savings, the estimated average out-of-pocket savings would be $140 (SE ± $15.8) per person per year, amounting to a total savings of $228,093,570 (SE ± $26,117,241). In multivariable regression models, lack of insurance coverage (adjusted odds ratio [OR] 3.5, 95%CI 1.9-6.5) and being prescribed a greater number of RxPass-eligible medications (2-3 medications versus 1 medication: OR 5.6, 95%CI 3.0-10.3; 4+ medications: OR 21.8, 95%CI 10.7-44.3) were each associated with a higher likelihood of achieving out-of-pocket savings from RxPass. CONCLUSIONS: Changes to the pricing structure of Amazon's direct-to-consumer medication service are needed to expand out-of-pocket savings on generic medications to a larger segment of the working-age adults with cardiovascular risk factors and/or diseases.
Assuntos
Doenças Cardiovasculares , Custos de Medicamentos , Fatores de Risco de Doenças Cardíacas , Humanos , Adulto , Pessoa de Meia-Idade , Masculino , Feminino , Estudos Transversais , Doenças Cardiovasculares/economia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/tratamento farmacológico , Adulto Jovem , Custos de Medicamentos/estatística & dados numéricos , Adolescente , Gastos em Saúde/estatística & dados numéricos , Estados Unidos , Medicamentos sob Prescrição/economia , Medicamentos Genéricos/economia , Medicamentos Genéricos/uso terapêutico , Redução de Custos , Assistência Farmacêutica/economiaRESUMO
Importance: Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. Objective: To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. Design, Setting, and Participants: This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Exposures: Hospital Value-Based Purchasing program HEA. Main Outcomes and Measures: Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Results: Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90â¯033) after HEA, ranging from a maximum reduction of $1â¯014â¯276 to a maximum increase of $1â¯523â¯765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28â¯971â¯708) and those caring for a higher proportion of Black patients ($15â¯468â¯445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Conclusions and Relevance: Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.
Assuntos
Atenção à Saúde , Economia Hospitalar , Equidade em Saúde , Medicare , Aquisição Baseada em Valor , Humanos , Estudos Transversais , Grupos Diagnósticos Relacionados/economia , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Elegibilidade Dupla ao MEDICAID e MEDICARE , Economia Hospitalar/estatística & dados numéricos , Equidade em Saúde/economia , Equidade em Saúde/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estados Unidos/epidemiologia , Aquisição Baseada em Valor/economia , Aquisição Baseada em Valor/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Provedores de Redes de Segurança/economia , Provedores de Redes de Segurança/etnologia , Provedores de Redes de Segurança/estatística & dados numéricos , População Rural , Atenção à Saúde/economia , Atenção à Saúde/etnologia , Atenção à Saúde/estatística & dados numéricosRESUMO
Importance: Since 2013, the American College of Cardiology (ACC) and American Heart Association (AHA) have recommended the pooled cohort equations (PCEs) for estimating the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). An AHA scientific advisory group recently developed the Predicting Risk of cardiovascular disease EVENTs (PREVENT) equations, which incorporated kidney measures, removed race as an input, and improved calibration in contemporary populations. PREVENT is known to produce ASCVD risk predictions that are lower than those produced by the PCEs, but the potential clinical implications have not been quantified. Objective: To estimate the number of US adults who would experience changes in risk categorization, treatment eligibility, or clinical outcomes when applying PREVENT equations to existing ACC and AHA guidelines. Design, Setting, and Participants: Nationally representative cross-sectional sample of 7765 US adults aged 30 to 79 years who participated in the National Health and Nutrition Examination Surveys of 2011 to March 2020, which had response rates ranging from 47% to 70%. Main Outcomes and Measures: Differences in predicted 10-year ASCVD risk, ACC and AHA risk categorization, eligibility for statin or antihypertensive therapy, and projected occurrences of myocardial infarction or stroke. Results: In a nationally representative sample of 7765 US adults aged 30 to 79 years (median age, 53 years; 51.3% women), it was estimated that using PREVENT equations would reclassify approximately half of US adults to lower ACC and AHA risk categories (53.0% [95% CI, 51.2%-54.8%]) and very few US adults to higher risk categories (0.41% [95% CI, 0.25%-0.62%]). The number of US adults receiving or recommended for preventive treatment would decrease by an estimated 14.3 million (95% CI, 12.6 million-15.9 million) for statin therapy and 2.62 million (95% CI, 2.02 million-3.21 million) for antihypertensive therapy. The study estimated that, over 10 years, these decreases in treatment eligibility could result in 107â¯000 additional occurrences of myocardial infarction or stroke. Eligibility changes would affect twice as many men as women and a greater proportion of Black adults than White adults. Conclusion and Relevance: By assigning lower ASCVD risk predictions, application of the PREVENT equations to existing treatment thresholds could reduce eligibility for statin and antihypertensive therapy among 15.8 million US adults.
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COVID-19 , Adulto , Humanos , COVID-19/epidemiologia , Pandemias , Pobreza , Insegurança AlimentarRESUMO
Health care payment reforms in the US have aimed to encourage the use of high-value care while discouraging the use of low-value care. However, little is known about whether the use of high- and low-value care differs by income level. Using data from the 2010-19 Medical Expenditure Panel Survey, we examined the use of specified types of high- and low-value care by income level. We found that high-income adults were significantly more likely than low-income adults to use nearly all types of high-value care. Findings were consistent across age categories, although differences by income level in the use of high-value care were smaller among the elderly. Our analysis of differences in the use of low-value care had mixed results. Among nonelderly adults, significant differences between those with high and low incomes were found for five of nine low-value services, and among elderly adults, significant differences by income level were found for three of twelve low-value services. Understanding the mechanisms underlying these disparities is crucial to developing effective policies and interventions to ensure equitable access to high-value care and discourage low-value services for all patients, regardless of income.
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Renda , Humanos , Estados Unidos , Adulto , Masculino , Pessoa de Meia-Idade , Feminino , Idoso , Gastos em Saúde/estatística & dados numéricos , Adulto Jovem , AdolescenteRESUMO
Asian Americans are often aggregated in national public health surveillance efforts, which may conceal important differences in the health status of subgroups that are included in this highly diverse population. Little is known about how cardiovascular health varies across Asian subpopulations and the extent to which lifestyle and social risk factors contribute to any observed differences. This national study used data from the National Health Interview Survey to evaluate the burden of cardiovascular risk factors (hypertension, hyperlipidemia, diabetes mellitus) and cardiovascular diseases (heart attack, coronary heart disease, angina, stroke) across Asian groups (Chinese, Asian Indian, Filipino, Other Asian), and determine whether differences are related to lifestyle factors and/or social determinants of health. The weighted study population included 13,592,178 Asian adults. Filipino adults were more likely to have hypertension than Chinese adults (29.4% vs 15.4%; adjusted odds ratio [OR] 2.40, 95% confidence interval [1.91 to 3.02]), as were Asian Indians (15.7%; OR 1.59 [1.25 to 2.02]). These patterns were similar for hyperlipidemia and diabetes mellitus. For cardiovascular diseases, Filipino adults were significantly more likely to have coronary heart disease (4.2% vs 1.9%; OR 2.19 [1.32 to 3.56]), heart attack (2.6% vs 0.9%; OR 2.79 [1.44 to 5.41]), angina (1.8% vs 0.9%; OR 2.15 [1.06 to 4.32]), and stroke (2.1% vs 0.8%; OR 2.54 [1.42 to 4.55]) compared with Chinese adults, whereas there were no differences compared with Asian Indian adults. Adjustments for lifestyle factors and social determinants completely attenuated differences in coronary heart disease, heart attack, and angina among subpopulations. In conclusion, these findings demonstrate that cardiovascular risk factors and diseases vary significantly across Asian subpopulations, with Filipino adults experiencing the highest burden and Chinese adults the lowest, and that differences in cardiovascular disease are largely attenuated after adjustment for lifestyle and social determinants.
Assuntos
Doenças Cardiovasculares , Doença das Coronárias , Diabetes Mellitus , Hiperlipidemias , Hipertensão , Infarto do Miocárdio , Acidente Vascular Cerebral , Adulto , Humanos , Angina Pectoris , Asiático , Doenças Cardiovasculares/epidemiologia , Hipertensão/epidemiologia , Estilo de Vida , Fatores de Risco , Determinantes Sociais da Saúde , Acidente Vascular Cerebral/epidemiologia , Estados Unidos/epidemiologia , EtnicidadeRESUMO
Importance: The COVID-19 pandemic led to unprecedented disruptions in health care. Little is known about whether health care access and preventive health screenings among US adults have recovered to prepandemic levels, and how patterns varied by race and ethnicity. Objective: To evaluate health care access and preventive health screenings among eligible US adults in 2021 and 2022 compared with prepandemic year 2019, overall and by race and ethnicity. Design, Setting, and Participants: This cross-sectional study used data from US adults aged 18 years or older who participated in the National Health Interview Survey in 2021 and 2022. Survey weights provided by the National Health Interview Survey were used to generate nationally representative estimates. Data were analyzed from May 23 to November 13, 2023. Main Outcomes and Measures: Measures of health care access included the proportion of adults with a usual place for care, those with a wellness visit, and those who delayed or did not receive medical care due to cost within the past year. Preventive health screening measures included eligible adults who received blood pressure, cholesterol, or blood glucose screening within the past year (2021), as well as colorectal, cervical, breast, and prostate cancer screenings based on US Preventive Services Task Force guidelines. Results: The unweighted study population included 89 130 US adults. The weighted population included 51.6% females; 16.8% Hispanic, 5.9% non-Hispanic Asian (hereafter, Asian), 11.8% non-Hispanic Black (hereafter, Black), 62.8% non-Hispanic White (hereafter, White) individuals; and 2.9% individuals of other races and ethnicities (including American Indian, Alaska Native, Native Hawaiian or other Pacific Islander, or multiracial). After adjusting for age and sex, having a usual place for health care did not differ among adults in 2021 or 2022 vs 2019 (adjusted rate ratio [ARR] for each year, 1.00; 95% CI, 0.99-1.01). However, fewer participants had wellness visits in 2022 compared with 2019 (ARR, 0.98; 95% CI, 0.97-0.99), with the most pronounced decline among Asian adults (ARR, 0.95; 95% CI, 0.92-0.98). In addition, adults were less likely to delay medical care (ARR, 0.79; 95% CI, 0.73-0.87) or to not receive care (ARR, 0.76; 95% CI, 0.69-0.83) due to cost in 2022 vs 2019. Preventive health screenings in 2021 remained below 2019 levels (blood pressure: ARR, 0.95 [95% CI, 0.94-0.96]; blood glucose: ARR, 0.95 [95% CI, 0.93-0.96]; and cholesterol: ARR, 0.93 [95% CI, 0.92-0.94]). Eligible adults were also significantly less likely to receive colorectal cancer screening (ARR, 0.88; 95% CI, 0.81-0.94), cervical cancer screening (ARR, 0.86; 95% CI, 0.83-0.89), breast cancer screening (ARR, 0.93; 95% CI, 0.90-0.97), and prostate cancer screening (ARR, 0.86 [0.78-0.94]) in 2021 vs 2019. Asian adults experienced the largest relative decreases across most preventive screenings, while Black and Hispanic adults experienced large declines in colorectal cancer screening (ARR, 0.78; 95% CI, 0.67-0.91) and breast cancer screening (ARR, 0.83; 95% CI, 0.75-0.91), respectively. Differences in preventive screening rates across years persisted after additional adjustment for socioeconomic factors (income, employment status, and insurance coverage). Conclusions and Relevance: Results of this cohort study suggest that, in the US, wellness visits and preventive health screenings have not returned to prepandemic levels. These findings support the need for public health efforts to increase the use of preventive health screenings among eligible US adults.
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Neoplasias da Mama , Neoplasias Colorretais , Neoplasias da Próstata , Neoplasias do Colo do Útero , Adulto , Masculino , Feminino , Humanos , Etnicidade , Detecção Precoce de Câncer , Estudos Transversais , Glicemia , Estudos de Coortes , Pandemias , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/prevenção & controle , Antígeno Prostático Específico , Serviços Preventivos de Saúde , Acessibilidade aos Serviços de Saúde , ColesterolRESUMO
The care of Black adults is highly concentrated at a limited set of US hospitals that often have limited resources. In 2011, the Medicare Hospital Value-Based Purchasing (VBP) Program began financially penalizing or rewarding hospitals based on thirty-day mortality rates for target conditions (myocardial infarction, heart failure, and pneumonia). Because the VBP Program has disproportionately penalized resource-constrained hospitals caring for high proportions of Black adults since its implementation in 2011, clinicians, health system leaders, and policy makers have worried that the program may unintentionally be widening racial disparities in health outcomes. Using Medicare claims for beneficiaries ages sixty-five and older who were hospitalized for three target conditions at 2,908 US hospitals participating in the VBP Program, we found that thirty-day mortality rates were consistently higher for two of three conditions at hospitals with high proportions of Black adults compared with other hospitals. There was no evidence of a differential change in thirty-day mortality among all Medicare beneficiaries with targeted conditions at high-proportion Black hospitals versus other hospitals seven years after the implementation of the VBP Program. However, gaps in mortality between these sites did widen in the subgroup of Black adults with pneumonia. These findings highlight that important concerns remain about the regressive nature and equity implications of national pay-for-performance programs.
Assuntos
Pneumonia , Reembolso de Incentivo , Estados Unidos , Adulto , Humanos , Idoso , Aquisição Baseada em Valor , Medicare , HospitaisRESUMO
BACKGROUND: Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades. METHODS: Medicare files were linked with the Centers for Disease Control and Prevention's social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries. RESULTS: A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990-650 per 100 000) and nondisadvantaged communities (950-570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02-1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13-1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063-1559 per 100 000) and nondisadvantaged communities (1767-1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146-184 per 100 000) and nondisadvantaged communities (153-184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01-1.20]). CONCLUSIONS: Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.
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Insuficiência Cardíaca , AVC Isquêmico , Infarto do Miocárdio , Embolia Pulmonar , Humanos , Feminino , Idoso , Estados Unidos/epidemiologia , Masculino , Medicare , Hospitalização , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Classe SocialRESUMO
Importance: In the US, the COVID-19 pandemic led to a significant rise in unemployment and economic loss that disproportionately impacted low-income individuals. It is unknown how health care and prescription medication affordability changed among low-income adults during the COVID-19 pandemic overall and compared with their higher-income counterparts. Objective: To evaluate changes in health care affordability and prescription medication affordability during the COVID-19 pandemic (2021 and 2022) compared with pre-COVID-19 pandemic levels (2019) and whether income-based inequities changed. Design, Setting, and Participants: This retrospective cross-sectional study included adults 18 years and older participating in the National Health Interview Survey (NHIS) in 2019, 2021, and 2022. Low-income adults were defined as having a household income of 200% or less of the federal poverty level (FPL); middle-income adults, 201% to 400% of the FPL; and high-income adults, more than 400% of the FPL. Data were analyzed from June to November 2023. Main Outcomes and Measures: Measures of health care affordability and prescription medication affordability. Results: The study population included 89â¯130 US adults. Among the weighted population, 51.6% (95% CI, 51.2-52.0) were female, and the mean (SD) age was 48.0 (0.12) years. Compared with prepandemic levels, during the COVID-19 pandemic, low-income adults were less likely to delay medical care (2022: 11.2%; 95% CI, 10.3-12.1; 2019: 15.4%; 95% CI, 14.3-16.4; adjusted relative risk [aRR], 0.73; 95% CI, 0.66-0.81) or avoid care (2022: 10.7%; 95% CI, 9.7-11.6; 2019: 14.9%; 95% CI, 13.8-15.9; aRR, 0.72; 95% CI, 0.64-0.80) due to cost, while high-income adults experienced no change, resulting in a significant improvement in income-based disparities. Low-income and high-income adults were less likely to experience problems paying medical bills but experienced no change in worrying about medical bills during the COVID-19 pandemic compared with prepandemic levels. Across measures of prescription medication affordability, low-income adults were less likely to delay medications (2022: 9.4%; 95% CI, 8.4-10.4; 2019: 12.7%; 95% CI, 11.6-13.9; aRR, 0.74; 95% CI, 0.65-0.84), not fill medications (2022: 8.9%; 95% CI, 8.1-9.8; 2019: 12.0%; 95% CI, 11.1-12.9; aRR, 0.75; 95% CI, 0.66-0.83), skip medications (2022: 6.7%; 95% CI, 5.9-7.6; 2019: 10.1%; 95% CI, 9.1-11.1; aRR, 0.67; 95% CI, 0.57-0.77), or take less medications (2022: 7.3%; 95% CI, 6.4-8.1; 2019: 11.2%; 95% CI, 10.%-12.2; aRR, 0.65; 95% CI, 0.56-0.74) due to costs, and these patterns were largely similar among high-income adults. Improvements in measures of health care and prescription medication affordability persisted even after accounting for changes in health insurance coverage and health care use. These patterns were similar when comparing measures of affordability in 2021 with 2019. Conclusions and Relevance: Health care affordability improved for low-income adults during the COVID-19 pandemic, resulting in a narrowing of income-based disparities, while prescription medication affordability improved for all income groups. These findings suggest that the recent unwinding of COVID-19 pandemic-related safety-net policies may worsen health care affordability and widen existing income-based inequities.
Assuntos
COVID-19 , Pobreza , Medicamentos sob Prescrição , Humanos , COVID-19/epidemiologia , Estudos Transversais , Estados Unidos/epidemiologia , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto , Medicamentos sob Prescrição/economia , Medicamentos sob Prescrição/uso terapêutico , Renda , Idoso , Acessibilidade aos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/tendências , Adulto Jovem , Adolescente , PandemiasRESUMO
Importance: The incidence of hospital encounters for acute myocardial infarction (AMI) decreased sharply early in the COVID-19 pandemic and has not returned to prepandemic levels. There has been an ongoing debate about what mechanism may underlie this decline, including patients avoiding the hospital for treatment, excess mortality from COVID-19 among patients who would otherwise have had an AMI, a reduction in the incidence or severity of AMIs due to pandemic-related changes in behavior, or a preexisting temporal trend of lower AMI incidence. Objective: To describe drivers of changing incidence in AMI hospital encounters during the COVID-19 pandemic. Design, Setting, and Participants: This cross-sectional study used traditional Medicare claims from all patients enrolled in traditional Medicare from January 2016 to June 2023 (total of 2.85 billion patient-months) to calculate the rate of AMI hospital encounters (emergency department visits, observation stays, or inpatient admissions) per capita at all short-term acute care and critical access hospitals in the United States overall and by patient characteristics. Observed rates were compared with expected rates that accounted for shifts in population characteristics and the prepandemic temporal trend (as estimated over 2016-2019). Data were analyzed in November 2023. Main Outcomes and Measures: Hospital encounters for AMI. Results: On average, the study sample included 31â¯623â¯928 patients each month from January 2016 through June 2023, for a total of 2â¯846â¯153â¯487 patient-months during the 90-month study period. In June 2023, there were 0.044 AMI hospital encounters per 100 patients, which was 20% lower than in June 2019 (0.055 encounters per 100 patients). Early in the pandemic, AMI rates moved inversely with COVID-19 death rates and tracked patterns seen for other painful acute conditions, such as nephrolithiasis, suggesting these changes were associated with care avoidance. Changes in patient characteristics driven by excess deaths during the pandemic explained little of the decline. Later in the pandemic, the decline may be explained by the long-standing downward trend in AMI incidence; by April 2022, the observed rate of encounters matched the expected rate that accounted for this trend. During the full pandemic period, from March 2020 to June 2023, there were an estimated 5% (95% prediction interval, 1%-9%) fewer AMI hospital encounters than expected. Conclusions and Relevance: The early reduction in AMI encounters was likely driven by care avoidance, while ongoing reductions through June 2023 likely reflect long-standing temporal trends. During the pandemic, there were 5% fewer AMI encounters than expected.
RESUMO
BACKGROUND: Home health care (HHC) has been increasingly used to improve care transitions and avoid poor outcomes, but there is limited data on its use and efficacy following coronary artery bypass grafting. The purpose of this study was to describe HHC use and its association with outcomes among Medicare beneficiaries undergoing coronary artery bypass grafting. METHODS: Retrospective analysis of 100% of Medicare fee-for-service files identified 77â 331 beneficiaries undergoing coronary artery bypass grafting and discharged to home between July 2016 and December 2018. The primary exposure of HHC use was defined as the presence of paid HHC claims within 30 days of discharge. Hierarchical logistic regression identified predictors of HHC use and the percentage of variation in HHC use attributed to the hospital. Propensity-matched logistic regression compared mortality, readmissions, emergency department visits, and cardiac rehabilitation enrollment at 30 and 90 days after discharge between HHC users and nonusers. RESULTS: A total of 26â 751 (34.6%) of beneficiaries used HHC within 30 days of discharge, which was more common among beneficiaries who were older (72.9 versus 72.5 years), male (79.4% versus 77.4%), White (90.2% versus 89.2%), and not Medicare-Medicaid dual eligible (6.7% versus 8.8%). The median hospital-level rate of HHC use was 31.0% (interquartile range, 13.7%-54.5%) and ranged from 0% to 94.2%. Nearly 30% of the interhospital variation in HHC use was attributed to the discharging hospital (intraclass correlation coefficient, 0.296 [95% CI, 0.275-0.318]). Compared with non-HHC users, those using HHC were less likely to have a readmission or emergency department visit, were more likely to enroll in cardiac rehabilitation, and had modestly higher mortality within 30 or 90 days of discharge. CONCLUSIONS: A third of Medicare beneficiaries undergoing coronary artery bypass grafting used HHC within 30 days of discharge, with wide interhospital variation in use and mixed associations with clinical outcomes and health care utilization.
Assuntos
Ponte de Artéria Coronária , Serviços de Assistência Domiciliar , Medicare , Readmissão do Paciente , Humanos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Estados Unidos , Masculino , Feminino , Idoso , Estudos Retrospectivos , Resultado do Tratamento , Fatores de Tempo , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/terapia , Fatores de Risco , Alta do Paciente , Benefícios do Seguro , Reabilitação Cardíaca , Planos de Pagamento por Serviço Prestado , Bases de Dados Factuais , Serviço Hospitalar de EmergênciaRESUMO
BACKGROUND: Lower-limb amputation rates in patients with chronic limb-threatening ischemia vary across the United States, with marked disparities in amputation rates by gender, race, and income status. We evaluated the association of patient, hospital, and geographic characteristics with the intensity of vascular care received the year before a major lower-limb amputation and how intensity of care associates with outcomes after amputation. METHODS: Using Medicare claims data (2016-2019), beneficiaries diagnosed with chronic limb-threatening ischemia who underwent a major lower-limb amputation were identified. We examined patient, hospital, and geographic characteristics associated with the intensity of vascular care received the year before amputation. Secondary objectives evaluated all-cause mortality and adverse events following amputation. RESULTS: Of 33â 036 total Medicare beneficiaries undergoing major amputation, 7885 (23.9%) were due to chronic limb-threatening ischemia; of these, 4988 (63.3%) received low-intensity and 2897 (36.7%) received high-intensity vascular care. Mean age, 76.6 years; women, 38.9%; Black adults, 24.5%; and of low income, 35.2%. After multivariable adjustment, those of low income (odds ratio, 0.65 [95% CI, 0.58-0.72]; P<0.001), and to a lesser extent, men (odds ratio, 0.89 [95% CI, 0.81-0.98]; P=0.019), and those who received care at a safety-net hospital (odds ratio, 0.87 [95% CI, 0.78-0.97]; P=0.012) were most likely to receive low intensity of care before amputation. High-intensity care was associated with a lower risk of all-cause mortality 2 years following amputation (hazard ratio, 0.79 [95% CI, 0.74-0.85]; P<0.001). CONCLUSIONS: Patients who were of low-income status, and to a lesser extent, men, or those cared for at safety-net hospitals were most likely to receive low-intensity vascular care. Low-intensity care was associated with worse long-term event-free survival. These data emphasize the continued disparities that exist in contemporary vascular practice.
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Procedimentos Endovasculares , Doença Arterial Periférica , Masculino , Humanos , Feminino , Idoso , Estados Unidos , Isquemia Crônica Crítica de Membro , Fatores de Risco , Resultado do Tratamento , Salvamento de Membro , Extremidade Inferior/irrigação sanguínea , Isquemia/diagnóstico , Isquemia/cirurgia , Medicare , Amputação Cirúrgica/efeitos adversos , Estudos Retrospectivos , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/cirurgiaRESUMO
Importance: The Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) program was launched in 2013 with a goal to improve care quality while lowering costs to Medicare. Objective: To compare changes in the quality and outcomes of care for patients hospitalized with heart failure according to hospital participation in the BPCI program. Design, Setting, and Participants: This cross-sectional study used a difference-in-difference approach to evaluate the BPCI program in 18 BPCI hospitals vs 211 same-state non-BPCI hospitals for various process-of-care measures and outcomes using American Heart Association Get With The Guidelines-Heart Failure registry and CMS Medicare claims data from November 1, 2008, to August 31, 2018. Data were analyzed from May 2022 to May 2023. Exposures: Hospital participation in CMS BPCI Model 2 Heart Failure, which paid hospitals in a fee-for-service process and then shared savings or required reimbursement depending on how the total cost of an episode of care compared with a target price. Main Outcomes and Measures: Primary end points included 7 quality-of-care measures. Secondary end points included 9 outcome measures, including in-hospital mortality and hospital-level risk-adjusted 30-day and 90-day all-cause readmission rate and mortality rate. Results: During the study period, 8721 patients were hospitalized in the 23 BPCI hospitals and 94â¯530 patients were hospitalized in the 224 same-state non-BPCI hospitals. Less than a third of patients (30â¯723 patients, 29.8%) were 75 years or younger; 54â¯629 (52.9%) were female, and 48â¯622 (47.1%) were male. Hospital participation in BPCI Model 2 was not associated with significant differential changes in the odds of various process-of-care measures, except for a decreased odds of evidence-based ß-blocker at discharge (adjusted odds ratio [aOR], 0.63; 95% CI, 0.41-0.98; P = .04). Participation in the BPCI was not associated with a significant differential change in the odds of receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors at discharge, receiving an aldosterone antagonist at discharge, having a cardiac resynchronization therapy (CRT)-defibrillator or CRT pacemaker placed or prescribed at discharge, having implantable cardioverter-defibrillator (ICD) counseling or an ICD placed or prescribed at discharge, heart failure education being provided among eligible patients, or having a follow-up visit within 7 days or less. Participation in the BPCI was associated with a significant decrease in odds of in-hospital mortality (aOR, 0.67; 95% CI, 0.51-0.86; P = .002). Participation was not associated with a significant differential change in hospital-level risk-adjusted 30-day or 90-day all-cause readmission rate and 30-day or 90-day all-cause mortality rate. Conclusion and Relevance: In this study, hospital participation in the BPCI Model 2 Heart Failure program was not associated with improvement in process-of-care quality measures or 30-day or 90-day risk-adjusted all-cause mortality and readmission rates.
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Insuficiência Cardíaca , Medicare , Humanos , Masculino , Feminino , Idoso , Estados Unidos , Estudos Transversais , Hospitais , Qualidade da Assistência à SaúdeRESUMO
BACKGROUND: Pulmonary vein isolation (PVI) is increasingly recommended as first-line therapy for atrial fibrillation. Recent data suggest growing PVI volumes but rising complication rates, although comprehensive real-world outcomes including both inpatient and outpatient encounters remain unclear. OBJECTIVES: The purpose of this study was to evaluate patient characteristics, population rates, and 30-day outcomes of PVI in a nationwide sample of U.S. adults aged >65 years. METHODS: First-time PVIs were identified among U.S. Medicare fee-for-service beneficiaries using Current Procedural Terminology procedural codes. Comorbidities were ascertained using International Classification of Diseases-10th Revision diagnosis codes associated with each procedural claim. Outcomes included periprocedural complications, all-cause hospitalizations, and mortality at 30 days. RESULTS: From January 2017 through December 2021, a total of 227,133 patients underwent PVI (mean age 72.5 years, 42% women, 92.7% White) with an increasing comorbidity burden over time. PVI volume increased from 83.8 (2017) to 111.6 per 100,000 patient-years (2021), which was driven by outpatient procedures (87.8% of all PVIs). Concurrently, there was a significant decrease in complication rates (3.9% in 2017 vs 3.1% in 2021; P < 0.001) and hospitalizations (8.8% vs 7.0%; P < 0.001), with no significant change in mortality (0.4%; P = 0.08). The most common periprocedural complications were bleeding (1.8%), pericardial effusion (1.4%), and vascular access damage (0.8%). CONCLUSIONS: The use of PVI has steadily increased among older patients in contemporary U.S. clinical practice; yet, cumulative complication and hospitalization rates at 30 days have decreased over time, with stably low rates of short-term mortality despite rising comorbidity burden among treated patients. These data may reassure patients and providers on the safety of PVI as an increasingly common first-line procedure for atrial fibrillation.
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Fibrilação Atrial , Ablação por Cateter , Humanos , Fibrilação Atrial/cirurgia , Fibrilação Atrial/epidemiologia , Idoso , Feminino , Masculino , Estados Unidos/epidemiologia , Ablação por Cateter/estatística & dados numéricos , Ablação por Cateter/efeitos adversos , Idoso de 80 Anos ou mais , Complicações Pós-Operatórias/epidemiologia , Hospitalização/estatística & dados numéricos , Resultado do Tratamento , Medicare/estatística & dados numéricos , Veias Pulmonares/cirurgia , ComorbidadeRESUMO
INTRODUCTION: The Russian invasion of Ukraine in February 2022 resulted in displacement of approximately 12.5 million refugees to adjacent countries, including Poland, which may have strained health care service delivery. OBJECTIVES: Using the STsegment elevation myocardial infarction (STEMI) data, we aimed to evaluate whether the Russian invasion of Ukraine has indirectly impacted delivery of acute cardiovascular care in Poland. PATIENTS AND METHODS: We analyzed all adult patients undergoing percutaneous coronary interventions (PCIs) for STEMI across Poland between February 25, 2017 and May 24, 2022. The investigated health care centers were allocated to regions below and over 100 km from the Polish-Ukrainian border. Mixedeffect generalized linear regression models with random effects per hospital were used to explore the associations between the war in Ukraine and several parameters, and whether these associations differed across the regions below and over 100 km from the border. RESULTS: A total of 90 115 procedures were included in the analysis. The average number of procedures per month was similar to the predicted volume for centers over 100 km from the border, while it was higher than expected (by an estimated median of 15 [interquartile range, 11-19]) for the region below 100 km from the border. There was no difference in adjusted fatality rate or quality of care outcomes for pre- and duringwar time in both regions, with no evidence of a differenceindifference across the regions. CONCLUSIONS: Following the Russian invasion of Ukraine, there was only a modest and temporary increase in the number of primary PCIs, predominantly in the centers situated within 100 km of the Polish-Ukrainian border, although no significant impact on inhospital fatality rate was found.
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Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Polônia , Intervenção Coronária Percutânea/estatística & dados numéricos , Ucrânia/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , Adulto , Conflitos ArmadosRESUMO
Background: Transcatheter aortic valve implantation (TAVI) rates are lower among Black compared with White individuals. However, it is unclear whether racial residential segregation, which remains common in the United States, contributes to observed disparities in TAVI rates. Objectives: The purpose of this study was to evaluate the association between county-level racial segregation, and aortic stenosis (AS) diagnosis, management, and outcomes. Methods: We identified Black and White Medicare fee-for-service beneficiaries age ≥65 years living in metropolitan areas of the United States (2016-2019). Using the American Community Survey's Black-White residential segregation index, a measure of geographic racial distribution, we determined segregation in each beneficiary's county of residence. Using hierarchical modeling, we determined the association between racial segregation and rates of AS diagnosis, TAVI receipt, and 30-day clinical outcomes (mortality, readmission, stroke). Results: There were 29,264,075 beneficiaries, of whom 22% lived in a high-segregation county. Among Black beneficiaries, high-segregation county residence was associated with decreased rates of AS diagnosis (OR: 0.97; 95% CI: 0.96-0.98) and TAVI (OR: 0.89; 95% CI: 0.86-0.93) compared with low-segregation county residence. In contrast, among White beneficiaries, high-segregation county residence was associated with higher rates of AS diagnosis (OR: 1.02; 95% CI: 1.02-1.03) and no differences in TAVI (OR: 1.00; 95% CI: 0.99-1.00). Segregation and race were not independently associated with 30-day mortality. Conclusions: Among Black Medicare fee-for-service beneficiaries, living in a high-segregation county was independently associated with decreased rates of AS diagnosis and TAVI, an association not seen among White beneficiaries. Residential racial segregation may contribute to racial disparities seen in AS care.