Association of the affordable care act's medicaid expansion with care quality and outcomes for low-income patients hospitalized with heart failure

Rishi K. Wadhera, Karen E. Joynt Maddox, Gregg C. Fonarow, Xin Zhao, Paul A. Heidenreich, Adam D. DeVore, Roland A. Matsouaka, Adrian F. Hernandez, Clyde W. Yancy, Deepak L. Bhatt*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

37 Scopus citations

Abstract

Background: Heart failure (HF) is the leading cause of morbidity and mortality in the United States. Despite advancement in the management of HF, outcomes remain suboptimal, particularly among the uninsured. In 2014, the Affordable Care Act expanded Medicaid eligibility, and millions of low-income adults gained insurance. Little is known about Medicaid expansion's effect on inpatient HF care. Methods and Results: We used the American Heart Association's Get With The Guidelines-Heart Failure registry to assess changes in inpatient care quality and outcomes among low-income patients (<65 years old) hospitalized for HF after Medicaid expansion, in expansion, and nonexpansion states. Patients were classified as low-income if covered by Medicaid, uninsured, or missing insurance. Expansion states were those that implemented expansion in 2014. Piecewise logistic multivariable regression models were constructed to track quarterly trends of quality and outcome measures in the pre (January 1, 2010-December 31, 2013) and postexpansion (January 1, 2014-June 30, 2017) periods. These measures were compared between expansion versus nonexpansion states during the postexpansion period. The cohort included 58 804 patients hospitalized across 391 sites. In states that expanded Medicaid, uninsured HF hospitalizations declined from 7.9% to 4.4%, and Medicaid HF hospitalizations increased from 18.3% to 34.6%. Defect-free HF care was increasing during the preexpansion period (adjusted odds ratio/quarter, 1.06; 95% confidence interval, 1.03-1.08) but did not change after expansion (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.02). Patterns were similar for other quality measures. There were no quality measures for which the rate of improvement sped up after expansion. In-hospital mortality rates remained similar during the preexpansion (adjusted odds ratio, 0.99; 95% confidence interval, 0.96-1.02) and postexpansion periods (adjusted odds ratio, 1.00; 95% confidence interval, 0.97-1.03). Among nonexpansion states, uninsured HF hospitalizations increased (11.6% to 16.7%) as did Medicaid HF hospitalizations (17.9% to 26.6%), and no quarterly improvement was observed for most quality measures in the post compared with preexpansion period. During the postexpansion period, defect-free care and mortality did not differ between expansion and nonexpansion states. Conclusions: Medicaid expansion was associated with a significant decline in uninsured HF hospitalizations but not improvements in quality of care or in-hospital mortality among sites participating in a national quality improvement initiative. Efforts beyond insurance expansion are needed to improve in-hospital outcomes for low-income patients with HF.

Original languageEnglish (US)
Article numbere004729
JournalCirculation: Cardiovascular Quality and Outcomes
Volume11
Issue number7
DOIs
StatePublished - Jul 1 2018

Funding

The Get With The Guidelines–Heart Failure (GWTG-HF) program is provided by the American Heart Association (AHA). GWTG-HF is sponsored, in part, by Amgen Cardiovascular and has been funded in the past through support from Medtronic, GlaxoSmithKline, Ortho-McNeil, and the AHA Pharmaceutical Roundtable. Dr Wadhera is supported by National Institutes of Health (NIH) Training Grant T32HL007604-32, Brigham and Women’s Hospital, Division of Cardiovascular Medicine and was also supported by the AHA Young Investigator Database Research Seed Grants. Dr Joynt Maddox receives research support from the National Heart, Lung, and Blood Institute (K23HL109177-03) and does contract work for the US Department of Health and Human Services. Dr Fonarow reports research support from the NIH, consulting for Amgen, Jans-sen, Medtronic, Novartis, and St Jude Medical, and serving on the GWTG Steering Committee. Dr Bhatt discloses the following relationships - he was a part of Advisory Board in Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors in Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair in AHA Quality Oversight Committee; Data Monitoring Committees in Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute), Cleveland Clinic, Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, Population Health Research Institute; received Honoraria from American College of Cardiology (ACC; Senior Associate Editor, Clinical Trials and News, ACC.org; Vice-Chair at ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; clinical trial steering committee), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the ACC (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (Continuing Medical Education steering committees); Other includes Clinical Cardiology (Deputy Editor), National Cardiovascular Data Registry ACTION Registry Steering Committee (Chair), Veterans Affairs Clinical Assessment Reporting and Tracking Program, Research and Publications Committee (Chair); received research funding from Abbott, Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, Regeneron, Roche, Sanofi Aventis, The Medicines Company; royalties from Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator at Biotronik, Boston Scientific, St. Jude Medical (now Abbott), Svelte; Trustee at American College of Cardiology; and Unfunded Research in FlowCo, Merck, PLx Pharma, Takeda. The other authors report no conflicts.

Keywords

  • Medicaid
  • Patient Protection and Affordable Care Act
  • heart failure
  • hospitalizations
  • insurance
  • mortality
  • quality of health care

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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