Publications

BACKGROUND: Medicare Advantage plans now provide health insurance coverage to >24 million older adults in the United States, and enrollment is increasing among individuals with cardiovascular disease (CVD). Whether Medicare Advantage enrollment is associated with similar health care access, acute care utilization, and financial strain for adults with CVD compared with traditional Medicare is unknown.

METHODS: We performed a cross-sectional study of Medicare beneficiaries 65 years or older with CVD using the 2019 National Health Interview Survey. We fit multivariable logistic regression models to examine the association of Medicare program type (Medicare Advantage versus traditional Medicare) with measures of health care access, acute care utilization, and affordability.

RESULTS: The weighted population included 11 013 437 Medicare beneficiaries, of whom 3 922 104 (35.6%) were enrolled in Medicare Advantage, and 7 091 334 (64.4%) were enrolled in traditional Medicare. Medicare Advantage and traditional Medicare enrollees were similar with respect to age, sex, racial/ethnic distribution, and household income; however, Medicare Advantage beneficiaries were more likely to live in an urban setting (82.7% versus 76.0%; P=0.01) and to be college educated (24.2% versus 19.0%; P=0.01). Medicare Advantage beneficiaries were more likely to have a usual source of care (93.5% versus 88.9%; OR, 1.99 [95% CI, 1.33-2.98)]; however, there were no other differences in health care access or utilization. Medicare Advantage beneficiaries were more likely to have problems paying medical bills (16.5% versus 11.6%; OR, 1.68 [1.17-2.40]) and to worry about paying medical bills (40.1% versus 33.8%; OR, 1.37 [1.07-1.76]) compared with those enrolled in traditional Medicare.

CONCLUSIONS: Adults with CVD in Medicare Advantage were more likely to experience financial strain related to their medical bills compared with those in traditional Medicare. As enrollment in Medicare Advantage grows, policy efforts should focus on ensuring care is affordable for patients with CVD.

BACKGROUND: Administrative claims for aortic stenosis (AS) regurgitation may be useful, but their accuracy and ability to identify individuals at risk for valve-related outcomes have not been well characterized.

METHODS: Using echocardiographic (transthoracic echocardiogram [TTE]) reports linked to US Medicare claims, 2017 to 2018, the performance of candidate International Classification of Diseases, Tenth Revision claims to ascertain AS/aortic regurgitation was evaluated. The optimal performing algorithm was tested against outcomes at 1-year after TTE in a separate 100% sample of US Medicare claims, 2017 to 2019.

RESULTS: Of those included in the derivation (N=5497, mean age 74.4±11.0 years, 49.7% female), any AS or aortic regurgitation was present in 24% and 38.8%, respectively. The sensitivity and specificity of International Classification of Diseases, Tenth Revision code I35.0 for identification of any AS was 53.1% and 94.8%, respectively. Among those with an I35.0 code, 40.3% had severe AS. Claims were unable to distinguish disease severity (ie, severe versus nonsevere) or subtype (eg, bicuspid or rheumatic AS), and were insensitive and nonspecific for aortic regurgitation of any severity. Among all beneficiaries who received a TTE (N=4 033 844), adjusting for age, sex, and 27 comorbidities, those with an I35.0 code had a higher adjusted risk of all-cause mortality (adjusted hazard ratio, 1.33 [95% CI, 1.31-1.34]), heart failure hospitalization (adjusted hazard ratio, 1.37 [95% CI, 1.34-1.41]), and aortic valve replacement (adjusted hazard ratio, 34.96 [95% CI, 33.74-36.22]).

CONCLUSIONS: Among US Medicare beneficiaries receiving a TTE, International Classification of Diseases, Tenth Revision claims, though identifying a population at significant greater risk of valve-related outcomes, failed to identify nearly half of individuals with AS and were unable to distinguish disease severity or subtype. These results argue against the widespread use of International Classification of Diseases, Tenth Revision claims to screen for patients with AS and suggests the need for improved coding algorithms and alternative systems to extract TTE data for quality improvement and hospital benchmarking.

IMPORTANCE: High lipid concentrations are a modifiable risk factor for cardiovascular disease. Little is known about how population-level lipid concentrations, as well as trends in lipid control, have changed over the past decade among US adults.

OBJECTIVE: To determine whether lipid concentrations and rates of lipid control changed among US adults and whether these trends differed by sex and race and ethnicity, from 2007 to 2018.

DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional analysis of 33 040 US adults aged 20 years or older, weighted to be nationally representative, from the National Health and Nutrition Examination Surveys (2007-2008 to 2017-2018).

MAIN OUTCOMES AND MEASURES: Lipid concentrations among US adults and rates of lipid control among adults receiving statin therapy. Lipid control was defined as a total cholesterol concentration of 200 mg/dL or less.

RESULTS: The mean age of the study population was 47.4 years, and 51.4% were women; of the 33 040 participants, 12.0% were non-Hispanic Black; 10.3%, Mexican American; 6.4%, other Hispanic American; 62.7%, non-Hispanic White; and 8.5%, other race and ethnicities (including non-Hispanic Asian. Among all US adults, age-adjusted total cholesterol improved significantly in the overall population from 197 mg/dL in 2007-2008 to 189 mg/dL in 2017-2018 (difference, -8.6 mg/dL [95% CI, -12.2 to -4.9 mg/dL]; P for trend <.001), with similar patterns for men and women. Black, Mexican American, other Hispanic, and White adults experienced significant improvements in total cholesterol, but no significant change was observed for Asian adults. Among adults receiving statin therapy, age-adjusted lipid control rates did not significantly change from 78.5% in 2007-2008 to 79.5% in 2017-2018 (difference, 1.1% [95% CI, -3.7% to 5.8%]; P for trend = .27), and these patterns were similar for men and women. Across all racial and ethnic groups, only Mexican Americans experienced a significant improvement in age-adjusted lipid control (P for trend = .008). In 2015-2018, age-adjusted rates of lipid control were significantly lower for women than for men (OR, 0.54 [95% CI, 0.40 to 0.72]). In addition, when compared with White adults, rates of lipid control while taking statins were significantly lower among Black adults (OR, 0.66 [95% CI, 0.47 to 0.94]) and other Hispanic adults (OR, 0.59 [95% CI, 0.37 to 0.95]); no significant differences were observed for other racial and ethnic groups.

CONCLUSIONS AND RELEVANCE: In this serial cross-sectional study, lipid concentrations improved in the US adult population from 2007-2008 through 2017-2018. These patterns were observed across all racial and ethnic subgroups, with the exception of non-Hispanic Asian adults.

IMPORTANCE: Safety-net hospitals, which have limited financial resources and care for disadvantaged populations, have lower performance on measures of patient experience than non-safety-net hospitals. In 2011, the Centers for Medicare & Medicaid Services Hospital Value-Based Purchasing (VBP) program began tying hospital payments to patient-reported experience scores, but whether implementation of this program narrowed differences in scores between safety-net and non-safety-net hospitals is unknown.

OBJECTIVE: To evaluate whether the VBP program's implementation was associated with changes in measures of patient-reported experience at safety-net hospitals compared with non-safety-net hospitals between 2008 and 2019.

DESIGN SETTING AND PARTICIPANTS: This cohort study evaluated 2266 US hospitals that participated in the VBP program between 2008 and 2019. Safety-net hospitals were defined as those in the highest quartile of the disproportionate share hospital index. Data were analyzed from December 2021 to February 2022.

MAIN OUTCOMES AND MEASURES: The primary outcomes were the Hospital Consumer Assessment of Healthcare Providers and Systems global measures of patient-reported experience and satisfaction, including a patient's overall rating of a hospital and willingness to recommend a hospital. Secondary outcomes included the 7 other Hospital Consumer Assessment of Healthcare Providers and Systems measures encompassing communication ratings, clinical processes ratings, and hospital environment ratings. Piecewise linear mixed regression models were used to assess annual trends in performance on each patient experience measure by hospital safety-net status before (July 1, 2007-June 30, 2011) and after (July 1, 2011-June 30, 2019) implementation of the VBP program.

RESULTS: Of 2266 US hospitals, 549 (24.2%) were safety-net hospitals. Safety-net hospitals were more likely than non-safety-net hospitals to be nonteaching (67.6% [371 of 549] vs 53.1% [912 of 1717]; P < .001) and urban (82.5% [453 of 549] vs 77.4% [1329 of 1717]; P = .01). Safety-net hospitals consistently had lower patient experience scores than non-safety-net hospitals across all measures from 2008 to 2019. The percentage of patients rating safety-net hospitals as a 9 or 10 out of 10 increased during the pre-VBP program period (annual percentage change, 1.84%; 95% CI, 1.73%-1.96%) and at a slower rate after VBP program implementation (annual percentage change, 0.49%; 95% CI, 0.45%-0.53%) at safety-net hospitals. Similar patterns were observed at non-safety-net hospitals (pre-VBP program annual percentage change, 1.84% [95% CI, 1.77%-1.90%] and post-VBP program annual percentage change, 0.42% [95% CI, 0.41%-0.45%]). There was no differential change in performance between these sites after the VBP program implementation (adjusted differential change, 0.07% [95% CI, -0.08% to 0.23%]; P = .36). These patterns were similar for the global measure that assessed whether patients would definitely recommend a hospital. There was also no differential change in performance between safety-net and non-safety-net hospitals under the VBP program across measures of communication, including doctor (adjusted differential change, -0.09% [95% CI, -0.19% to 0.01%]; P = .08) and nurse (adjusted differential change, -0.01% [95% CI, -0.12% to 0.10%]; P = .86) communication as well as clinical process measures (staff responsiveness adjusted differential change, 0.13% [95% CI, -0.03% to 0.29%]; P = .11; and discharge instructions adjusted differential change, -0.02% [95% CI, -0.12% to 0.07%]; P = .62).

CONCLUSIONS AND RELEVANCE: This cohort study of 2266 US hospitals found that the VBP program was not associated with improved patient experience at safety-net hospitals vs non-safety-net hospitals during an 8-year period. Policy makers may need to explore other strategies to address ongoing differences in patient experience and satisfaction, including additional support for safety-net hospitals.

This cross-sectional study examines the number and characteristics of hospitals that performed well or poorly across 3 Medicare value-based programs in fiscal year 2020.

BACKGROUND: The COVID-19 pandemic has disproportionately affected low-income and racial/ethnic minority populations in the United States. However, it is unknown whether hospitalized patients with COVID-19 from socially vulnerable communities experience higher rates of death and/or major adverse cardiovascular events (MACEs). Thus, we evaluated the association between county-level social vulnerability and in-hospital mortality and MACE in a national cohort of hospitalized COVID-19 patients.

METHODS: Our study population included patients with COVID-19 in the American Heart Association COVID-19 Cardiovascular Disease Registry across 107 US hospitals between January 14, 2020 to November 30, 2020. The Social Vulnerability Index (SVI), a composite measure of community vulnerability developed by Centers for Disease Control and Prevention, was used to classify the county-level social vulnerability of patients' place of residence. We fit a hierarchical logistic regression model with hospital-level random intercepts to evaluate the association of SVI with in-hospital mortality and MACE.

RESULTS: Among 16 939 hospitalized COVID-19 patients in the registry, 5065 (29.9%) resided in the most vulnerable communities (highest national quartile of SVI). Compared with those in the lowest quartile of SVI, patients in the highest quartile were younger (age 60.2 versus 62.3 years) and more likely to be Black adults (36.7% versus 12.2%) and Medicaid-insured (31.1% versus 23.0%). After adjustment for demographics (age, sex, race/ethnicity) and insurance status, the highest quartile of SVI (compared with the lowest) was associated with higher likelihood of in-hospital mortality (OR, 1.25 [1.03-1.53]; P=0.03) and MACE (OR, 1.26 [95% CI, 1.05-1.50]; P=0.01). These findings were not attenuated after accounting for clinical comorbidities and acuity of illness on admission.

CONCLUSIONS: Patients hospitalized with COVID-19 residing in more socially vulnerable communities experienced higher rates of in-hospital mortality and MACE, independent of race, ethnicity, and several clinical factors. Clinical and health system strategies are needed to improve health outcomes for socially vulnerable patients.