Abstract
Background: Uninsurance is a known contributor to racial/ethnic health inequities. Insurance is often needed for prescriptions and follow-up appointments. Therefore, we determined whether the Affordable Care Act(ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment(GDMT) at discharge among patients hospitalized with heart failure(HF) by race/ethnicity. Methods: Using Get With The Guidelines-HF registry, logistic regression was used to assess odds of receiving GDMT(HF medications; education; follow-up appointment) in early vs non-adopter states before(2012 – 2013) and after ACA Medicaid Expansion(2014 – 2019) within each race/ethnicity, accounting for patient-level covariates and within-hospital clustering. We tested for an interaction(p-int) between GDMT and pre/post Medicaid Expansion time periods. Results: Among 271,606 patients(57.5% early adopter, 42.5% non-adopter), 65.5% were White, 22.8% African American, 8.9% Hispanic, and 2.9% Asian race/ethnicity. Independent of ACA timing, Hispanic patients were more likely to receive all GDMT for residing in early adopter states compared to non-adopter states (P <.0001). In fully-adjusted analyses, ACA Medicaid Expansion was associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients [before ACA:OR 0.40(95%CI:0.13,1.23); after ACA:OR 2.46(1.10,5.51); P-int = .0002], but this occurred in the setting of an immediate decline in prescribing patterns, particularly among non-adopter states, followed by an increase that remained lowest in non-adopter states. The ACA was not associated with receipt of GDMT for other racial/ethnic groups. Conclusions: Among GWTG-HF hospitals, Hispanic patients were more likely to receive all GDMT if they resided in early adopter states rather than non-adopter states, independent of ACA Medicaid Expansion timing. ACA implementation was only associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients. Additional steps are needed for improved GDMT delivery for all.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 135-148 |
| Number of pages | 14 |
| Journal | American heart journal |
| Volume | 244 |
| DOIs | |
| State | Published - Feb 2022 |
Funding
Dr. Sweitzer has research grants from Novartis and Merck. Dr. Fonarow has consulting funding from Abbott, Amgen, Astra Zeneca, Bayer, CHF Solutions, Merck, Medtronic, Novartis. Dr. DeVore has research funding from AHA, Amgen, Bayer, Intra-Cellular Therapies, Luitpold Pharmaceuticals, NHLBI, Novartis and PCORI; consulting funding from Amgen, AstraZeneca, Bayer, InnaMed, LivaNova, Mardil Medical, Novartis, Procyrion, scPharmaceuticals, and Zoll. Dr. Bhatt discloses the following relationships - Advisory Board: Cardax, Cereno Scientific, Elsevier Practice Update Cardiology, Medscape Cardiology, PhaseBio, PLx Pharma, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice-Chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), Svelte; Trustee: American College of Cardiology; Unfunded Research: FlowCo, Merck, Novo Nordisk, Takeda. GWTG-HF is sponsored, in part, by Novartis, Boehringer Ingelheim, Lilly, Novo Nordisk, Sanofi, AstraZeneca and Bayer. GWTG-HF is an established registry of over 600 voluntary hospitals across the U.S. that are dedicated to improving quality of patient care and performance of hospitals. Participating hospitals receive support to improve healthcare delivery through education, access to the latest clinical data, and ongoing performance feedback. 14 The database includes all inpatient hospitalizations for HF among adults aged 18 years and older. 15 Demographics including race and ethnicity as well as clinical information are uploaded into the registry by respective hospital sites. Race and ethnicity were categorized by self-report on case forms. Race options included: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, and unable to determine. Ethnicity options included Hispanic ethnicity. As a quality improvement program, participating hospitals had waivers for informed consent under the common rule and were required to obtain institutional review board approval. 16 Analytic method are available upon request from the study team. Data is not publicly available, and requests for data should go to American Heart Association GWTG-HF. This study was directly funded by Dr. Breathett's American Heart Association (AHA) Get With the Guidelines Young Investigator Database Seed Grant Award; and National Heart, Lung, and Blood Institute (NHLBI) K01HL142848, R56HL159216, R25HL126146 subaward 11692sc, and L30HL148881. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents. Dr. Breathett has research funding from American Heart Association (AHA) Get With the Guidelines Young Investigator Database Seed Grant Award; National Heart, Lung, and Blood Institute (NHLBI) K01HL142848, R56HL159216, R25HL126146 subaward 11692sc, and L30HL148881; University of Arizona Health Sciences, Strategic Priorities Faculty Initiative Grant; University of Arizona, Sarver Heart Center, Novel Research Project Award in the Area of Cardiovascular Disease and Medicine, Anthony and Mary Zoia Research Award; and Women As One. Dr. Peterson has funding from NHLBI. The Get With The GuidelinesHeart Failure (GWTG-HF) program is provided by the American Heart Association.
Keywords
- evidence-based medicine
- health policy
- heart failure
- hospitalization
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine
