Follow-up care after CV hospitalization rising, but not for some groups
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Key takeaways:
- Follow-up care after CV events rose, but gaps remain for Black and Medicaid dual-eligible patients.
- This may partly be an unintended effect of the CMS bundled payment program for transitional care management.
Overall rates of postdischarge follow-up care after heart disease hospitalization has increased, but gaps in follow-up care for Black and Medicaid dual-eligible patients widened, researchers reported.
“One potential avenue for improving postdischarge outcomes is early clinician follow-up to assist in care coordination, medication titration and early detection of clinical deterioration,” Timothy S. Anderson, MD, MAS, assistant professor of medicine at the Center for Research on Health Care at the University of Pittsburgh, and colleagues wrote. “Recognizing this potential benefit, CMS implemented in 2013 a bundled payment program, known as transitional care management (TCM), which provides additional financial incentives to outpatient clinicians for managing the first 30 days of patients’ transition to the community after discharge from hospitals or nursing homes. ... Contemporary data on rates of postdischarge follow-up are not well characterized.”
Anderson and colleagues conducted a retrospective study of all Medicare fee-for-service beneficiaries with an acute MI or HF hospitalization from 2010 to 2019 to examine trends in timely postdischarge follow-up and whether disparities exist.
The results of the present study were published in the Annals of Internal Medicine.
The analysis included more than 1.6 million acute MI hospitalizations and more than 4.2 million HF hospitalizations.
Among patients in the acute MI cohort, 12.8% were younger than 65 years; 36.5% were older than 80 years; 45% were women; and 82% were white. For the HF cohort, 12.9% were younger than 65 years; 48.1% were older than 80 years; 52% were women; and 75% were white.
From 2010 to 2019, the cardiology follow-up rate increased from 48.3% to 61.4% for acute MI hospitalizations and from 35.2% to 48.3% for HF hospitalizations; however, disparities in follow-up rates widened for Hispanic patients with acute MI and for Black, Asian and Hispanic patients with HF.
In addition, Medicaid dual-eligible patients and residents of counties with higher levels of social deprivation with HF also experienced widening gaps in the rate of cardiology follow-up from 2010 to 2019.
By 2019, the largest disparities were observed between Black patients and white patients, with Black patients having an average follow-up rate 7.9 percentage points lower for acute MI and 8.9 percentage points lower for HF.
A wide disparity was also reported between Medicaid dual-eligible and nondual-eligible patients, with dual-eligible patients having an average follow-up rate 7.6 percentage points lower for acute MI and 9.6 percentage points lower for HF.
Upon further analysis of hospital characteristics, Anderson and colleagues reported approximately 7.3 percentage points of variation in follow-up after acute MI hospitalization and 7.7 percentage points of variation after HF hospitalization was attributable to the hospitals, with the respective remainders attributable to individual variation.
“The combination of the positive financial incentive created by the TCM program and the financial penalty posed by Hospital Readmissions Reduction Program to hospitals with higher-than-expected 30-day readmission rates effectively shifts CMS payments from low-performing hospitals to high-performing ambulatory clinics,” the researchers wrote. “This shift may, in part, explain the observed worsening demographic and socioeconomic disparities in follow-up.
“Our findings of growing disparities in follow-up for Black, Hispanic and socioeconomically disadvantaged groups, in conjunction with prior literature describing disparities in ambulatory care access broadly, further show the potential for unanticipated effects of health policy on inequities,” they wrote.
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