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Association of the Affordable Care Act's Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure.

Publication ,  Journal Article
Wadhera, RK; Joynt Maddox, KE; Fonarow, GC; Zhao, X; Heidenreich, PA; DeVore, AD; Matsouaka, RA; Hernandez, AF; Yancy, CW; Bhatt, DL
Published in: Circ Cardiovasc Qual Outcomes
July 2018

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.

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Published In

Circ Cardiovasc Qual Outcomes

DOI

EISSN

1941-7705

Publication Date

July 2018

Volume

11

Issue

7

Start / End Page

e004729

Location

United States

Related Subject Headings

  • United States
  • Treatment Outcome
  • Time Factors
  • Registries
  • Quality Indicators, Health Care
  • Quality Improvement
  • Poverty
  • Policy Making
  • Patient Protection and Affordable Care Act
  • Outcome and Process Assessment, Health Care
 

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Wadhera, R. K., Joynt Maddox, K. E., Fonarow, G. C., Zhao, X., Heidenreich, P. A., DeVore, A. D., … Bhatt, D. L. (2018). Association of the Affordable Care Act's Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure. Circ Cardiovasc Qual Outcomes, 11(7), e004729. https://doi.org/10.1161/CIRCOUTCOMES.118.004729
Wadhera, Rishi K., Karen E. Joynt Maddox, Gregg C. Fonarow, Xin Zhao, Paul A. Heidenreich, Adam D. DeVore, Roland A. Matsouaka, Adrian F. Hernandez, Clyde W. Yancy, and Deepak L. Bhatt. “Association of the Affordable Care Act's Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure.Circ Cardiovasc Qual Outcomes 11, no. 7 (July 2018): e004729. https://doi.org/10.1161/CIRCOUTCOMES.118.004729.
Wadhera RK, Joynt Maddox KE, Fonarow GC, Zhao X, Heidenreich PA, DeVore AD, et al. Association of the Affordable Care Act's Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure. Circ Cardiovasc Qual Outcomes. 2018 Jul;11(7):e004729.
Wadhera, Rishi K., et al. “Association of the Affordable Care Act's Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure.Circ Cardiovasc Qual Outcomes, vol. 11, no. 7, July 2018, p. e004729. Pubmed, doi:10.1161/CIRCOUTCOMES.118.004729.
Wadhera RK, Joynt Maddox KE, Fonarow GC, Zhao X, Heidenreich PA, DeVore AD, Matsouaka RA, Hernandez AF, Yancy CW, Bhatt DL. Association of the Affordable Care Act's Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure. Circ Cardiovasc Qual Outcomes. 2018 Jul;11(7):e004729.

Published In

Circ Cardiovasc Qual Outcomes

DOI

EISSN

1941-7705

Publication Date

July 2018

Volume

11

Issue

7

Start / End Page

e004729

Location

United States

Related Subject Headings

  • United States
  • Treatment Outcome
  • Time Factors
  • Registries
  • Quality Indicators, Health Care
  • Quality Improvement
  • Poverty
  • Policy Making
  • Patient Protection and Affordable Care Act
  • Outcome and Process Assessment, Health Care