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Original Investigation
April 7, 2021

Association of Dual Eligibility for Medicare and Medicaid With Heart Failure Quality and Outcomes Among Get With The Guidelines–Heart Failure Hospitals

Author Affiliations
  • 1Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles
  • 2Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
  • 3Fielding School of Public Health, University of California, Los Angeles
  • 4Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 5Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
  • 6Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
  • 7Department of Medicine, Stanford School of Medicine, Palo Alto, California
  • 8Division of Cardiology, University of Colorado School of Medicine, Aurora
  • 9Deputy Editor, JAMA Cardiology
  • 10Ahmanson Cardiomyopathy Center, David Geffen School of Medicine, University of California, Los Angeles
  • 11Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
JAMA Cardiol. Published online April 7, 2021. doi:10.1001/jamacardio.2021.0611
Key Points

Question  What is the association between the proportion of dual-eligible Medicare and Medicaid beneficiaries at the hospital level with quality of care and outcomes for heart failure (HF)?

Findings  In this cohort study, patients treated at hospitals with the highest proportion of dual-eligible beneficiaries were less likely to receive important HF process measures, including evidence-based β-blocker prescription on discharge, measurement of left ventricular function, and anticoagulation for atrial fibrillation or atrial flutter, and had significantly higher 30-day all-cause or HF readmissions.

Meaning  Targeting disparities in HF in hospitals that have a higher share of dual-eligible beneficiaries could help bridge the gap in HF quality of care and outcomes demonstrated across socioeconomic statuses.

Abstract

Importance  The Centers for Medicare & Medicaid Services uses a new peer group–based payment system to compare hospital performance as part of its Hospital Readmissions Reduction Program, which classifies hospitals into quintiles based on their share of dual-eligible beneficiaries for Medicare and Medicaid. However, little is known about the association of a hospital’s share of dual-eligible beneficiaries with the quality of care and outcomes for patients with heart failure (HF).

Objective  To evaluate the association between a hospital’s proportion of patients with dual eligibility for Medicare and Medicaid and HF quality of care and outcomes.

Design, Setting, and Participants  This retrospective cohort study evaluated 436 196 patients hospitalized for HF using the Get With The Guidelines–Heart Failure registry from January 1, 2010, to December 31, 2017. The analysis included patients 65 years or older with available data on dual-eligibility status. Hospitals were divided into quintiles based on their share of dual-eligible patients. Quality and outcomes were analyzed using unadjusted and adjusted multivariable logistic regression models. Data analysis was performed from April 1, 2020, to January 1, 2021.

Main Outcomes and Measures  The primary outcome was 30-day all-cause readmission. The secondary outcomes included in-hospital mortality, 30-day HF readmissions, 30-day all-cause mortality, and HF process of care measures.

Results  A total of 436 196 hospitalized HF patients 65 years or older from 535 hospital sites were identified, with 258 995 hospitalized patients (median age, 81 years; interquartile range, 74-87 years) at 455 sites meeting the study criteria and included in the primary analysis. A total of 258 995 HF hospitalizations from 455 sites were included in the primary analysis of the study. Hospitals in the highest dual-eligibility quintile (quintile 5) tended to care for patients who were younger, were more likely to be female, belonged to racial minority groups, or were located in rural areas compared with quintile 1 sites. After multivariable adjustment, hospitals with the highest quintile of dual eligibility were associated with lower rates of key process measures, including evidence-based β-blocker prescription, measure of left ventricular function, and anticoagulation for atrial fibrillation or atrial flutter. Differences in clinical outcomes were seen with higher 30-day all-cause (adjusted odds ratio, 1.24; 95% CI, 1.14-1.35) and HF (adjusted odds ratio, 1.14; 95% CI, 1.03-1.27) readmissions in higher dual-eligible quintile 5 sites compared with quintile 1 sites. Risk-adjusted in-hospital and 30-day mortality did not significantly differ in quintile 1 vs quintile 5 hospitals.

Conclusions and Relevance  In this cohort study, hospitals with a higher share of dual-eligible patients provided care with lower rates of some of the key HF quality of care process measures and with higher 30-day all-cause or HF readmissions compared with lower dual-eligibility quintile hospitals.

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