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Comorbidities, secondary prevention more likely in Medicare Advantage beneficiaries with CAD
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Patients who were Medicare Advantage beneficiaries had more comorbidities compared with patients who were fee-for-service Medicare beneficiaries, according to a study published in JAMA Cardiology.
The Medicare Advantage beneficiary group was also more likely to receive secondary prevention treatments vs. the fee-for-service Medicare beneficiary group, according to the study.
“To our knowledge, this study represents the first national comparison study examining quality of care using detailed clinical data among patients enrolled in Medicare by insurance status,” Jose F. Figueroa, MD, MPH, assistant professor of medicine at Brigham and Women’s Hospital, and colleagues wrote.
PINNACLE registry data
Researchers analyzed data from 35,563 patients (mean age, 77 years; 57% men) enrolled in Medicare Advantage and 172,732 patients (mean age, 78 years; 58% men) enrolled in fee-for-service Medicare from the PINNACLE registry who had CAD between 2013 and May 2014. CAD was defined as a history of MI, CABG or PCI. Information collected at the last patient encounter included patient characteristics such as sex, age, race/ethnicity and dual eligibility for Medicaid and Medicare.
The outcome of interest was patient eligibility for guideline-recommended CAD therapy, including ACE inhibitors, beta-blockers and statin therapy. Intermediate outcomes of interest included LDL concentration and both systolic and diastolic BP.
Compared with patients enrolled in fee-for-service Medicare, those enrolled in Medicare Advantage were more likely to be white (69.8% vs. 73.7%; P < .001), younger (76.7 years vs. 77.5 years; P < .001), women (43.2% vs. 42.1%; P < .001) and have conditions such as diabetes (31.6% vs. 28%; P < .001), HF (36.6% vs. 34.6%; P < .001) and chronic kidney disease (6.6% vs. 5.6%; P < .001).
Patients enrolled in Medicare Advantage were more likely to receive secondary prevention strategies such as ACE inhibitors or angiotensin II receptor blockers (70.7% vs. 65.1%; P < .001), beta-blockers (80.6% vs. 78.8%; P < .001) and statins (68.4% vs. 64.5%; P < .001) compared with those enrolled in fee-for-service Medicare. When eligible, these patients were also more likely to receive all three medications (48.9% vs. 40.4%; P < .001).
Adjustment for comorbidities
After adjusting for comorbidities and patient characteristics, patients who were Medicare Advantage beneficiaries had higher odds for receiving guideline-recommended therapy that included beta-blockers (OR = 1.1; 95% CI, 1.04-1.17), ACE inhibitors and angiotensin II receptor blockers (OR = 1.13; 95% CI, 1.08-1.19), and all three medications (OR = 1.23; 95% CI, 1.001-1.5) compared with those who were fee-for-service Medicare beneficiaries.
There were no significant differences between both groups for LDL levels, systolic BP or diastolic BP.
“As [Medicare Advantage] continues to enroll a higher proportion of beneficiaries each year, it will be important to monitor both quality and outcomes of care to determine whether these patterns ultimately lead to better outcomes in Medicare,” Figueroa and colleagues wrote.
“In summary, as tempting as it may be, we should not let the lack of an observational outcome supersede a benefit in a process of care that is shown to improve outcomes in randomized clinical trials,” Paul Heidenreich, MD, MS, professor of medicine (cardiovascular) at Stanford University School of Medicine and professor of health research and policy at the Palo Alto Veterans Affairs Health Care System in California, wrote in a related editorial. “The low-quality signal-to-noise ratio for observational outcome measures, combined with the huge sample size that is needed to show an outcome difference given a small process of care difference, makes a null outcome finding difficult to interpret. We will be more accurate and helpful to health system users by combining process and outcome measures when assessing and labeling quality of care.” – by Darlene Dobkowski
Disclosures: Figueroa reports he is partially funded by a grant from the National Center for Advancing Translational Sciences. Heidenreich reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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