Recovery from a cardiac-related hospitalization requires coordinated, timely care to prevent a return to the hospital for an avoidable readmission. A new study concludes that while the picture is getting brighter for all Medicare patients, persistent racial disparities are widening.
Poorer and rural patients were also less likely to have prompt post-discharge visits to check on issues such as medication, a common contributor to readmission.
The study, based on Medicare claims data over 10 years and published Monday in the Annals of Internal Medicine, looked at whether patients with heart attack or heart failure had a visit with a cardiologist or a primary care clinician within the critical month after discharge.
After nearly 6 million patients were hospitalized for these serious heart diseases from 2010 through 2019, post-discharge visits with a cardiology clinician went up from 48.3% to 61.4% of heart attack patients and from 35.2% to 48.3% of heart failure patients. Still, more than 20% of patients with heart attacks and 30% of patients with heart failure were not seen by either a primary care or a cardiology clinician within 30 days of leaving the hospital.
The largest racial and ethnic gaps were between Black and white patients. For heart attack follow-up care within a month, 52% of Black patients but 60% of white patients received it; for heart failure, it was 40% of Black patients versus 49% of white patients.
There was also a difference between heart attack patients who were eligible for both Medicare and Medicaid, seen as a proxy for lower income and higher social disadvantage. Of the dual-eligible, 53% had prompt follow-up visits versus 60% of the non-dual eligible after heart attack; for heart failure, it was 40% versus 49%.
Existing disparities grew larger for Asian, Black, and Hispanic patients as well as for patients eligible to receive both Medicare and Medicaid, and for people living in counties that had higher levels of social deprivation.
How much wider was the gap with white patients? After a heart attack, the difference for Hispanic patients grew from 2 percentage points in 2010 to 6 percentage points in 2019. After heart failure hospitalization, for Asian patients, the disparity rose from 2 to 8 percentage points; for Black patients, from 7 to 9 percentage points; for Hispanic patients, 5 to 8 percentage points; and between dual-eligible and other patients, from 9 to 10 percentage points.
“It’s reassuring to see that we are making progress towards improving post-hospital care in two decades in which we focused so much on post-hospital outcomes, but we haven’t looked at whether we’re actually getting care to people when they leave the hospital,” Timothy Anderson, assistant professor of medicine at the University of Pittsburgh and study co-author, said in an interview. “The goal of our study is to understand not just have we had improvements in post-hospital care, but how equitable those improvements have been.”
Patients in the analysis belonged to Medicare’s fee-for-services program, so they were not members of Medicare Advantage plans.
One of the biggest barriers to post-discharge care for many patients can be lack of easy access to a doctor, nurse practitioner, or physician assistant. Finding cardiac specialists is particularly difficult for rural patients.
“Patients could be admitted for a heart attack, then they just get sent home and may be told they need to go check in with a doctor, but they don’t have someone to follow-up to,” said Michael Thompson, an assistant professor in cardiac surgery at Michigan Medicine, who was not involved in the new study. “Continuity of care assumes that there’s already continuity of care before the event, which isn’t always the case.”
Follow-up is important for many reasons. Clinicians can monitor patients’ recovery, adjust their medications, and figure out other care as they make the transition from hospital to home. Patients may need lab tests or imaging studies, plus rehabilitation to resume the activities of daily living and get advice on improving their diet and exercise habits. They also need instruction on how to watch for complications from their heart disease that need medical attention and for some, help with the depressive symptoms that are common after a heart attack.
Previous research has connected timely follow-up to better consistency when it comes to taking medications, which in turn is associated with lower readmission rates among heart failure patients in particular, who are more vulnerable to setbacks that send them back to a hospital. Heart failure is diagnosed when the heart can’t pump blood throughout the body as well as it should.
“Once somebody leaves the hospital, that’s really the lever to help people’s outcomes,” Anderson said.
The researchers looked more closely at groups of patients already known to experience disparities in their cardiovascular outcomes.
“If we’re improving overall rates, but the disparities are widening, are we really doing a good job of improving care for all?” said Thompson, whose research focuses on understanding quality and value in health care, especially for patients with cardiovascular disease. “And the answer is clearly, probably not.”
The analysis uncovered differences both within and between hospitals. Within a hospital, follow-up visits remained lower for patients who were Black or Hispanic, lived in a rural area, qualified for both Medicaid and Medicare, and whose county met a social deprivation score.
In hospitals where the proportion of Medicaid dual-eligible patients was 20% higher than at other hospitals, the odds of follow-up visits were 21% lower after heart attack and 25% lower after heart failure. Smaller differences were seen between hospitals for female, rural, and Black patients in their patient census.
The researchers suspect a policy introduced to lower hospital readmission rates had unintended consequences reflected in follow-up visits. A Medicare-funded initiative through the Affordable Care Act encouraged transitional care management by offering financial incentives for connecting patients to outpatient clinicians who would manage those first 30 days after returning home from a hospital or a nursing home.
Medicare payments to safety-net hospitals — which may take care of sicker, more complicated, and more disadvantaged patients — ended up being lower than to better-equipped hospitals serving higher-income patients.
“The challenge with that program, which is also well-intentioned, is that you have to have a really good infrastructure to make it work because you have to have a nurse call the patient within two days,” Anderson said. “If you’re an under-resourced safety-net clinic, you may not know for a couple of days that your patient was discharged from a hospital because you’re not part of the health system where the clinic and the hospital are all together on the same page.”
The authors offered several ideas to narrow gaps in care. Telehealth could help connect patients and doctors more quickly and easily than in-person visits.
But Shivani Patel, an epidemiologist at Emory University’s Rollins School of Public Health whose research focuses on cardiometabolic health, noted the digital divide between rural and urban residents when it comes to connectivity to telehealth and perhaps digital literacy. Patel was not involved in the study but called it well conducted, using a solid data infrastructure and strong methodology.
“If we have a telehealth visit versus an in-person visit, are we able to reduce the risk of a future readmission?” she said. “This is a very high-risk population for mortality. It’s also a population, in terms of all the cardiovascular conditions in a population that can be socioeconomically more disadvantaged, facing multiple barriers at home in terms of managing their care. And then it looks like we’re failing to see them in a timely manner.”
“Telehealth can begin to close that gap, but I think we would need to know subsequently, is it actually working as well as the in-person?”
Telehealth has shown promise for one post-discharge piece: cardiac rehab, a program combining counseling with exercise to improve heart health following treatment for heart attack or other illness. Some trials have shown that virtual or hybrid cardiac rehab is just as good as an in-person program, which ideally could help with travel or geographic barriers, Thompson said.
Another fix could come from better sharing of electronic health records across health systems so clinicians outside the hospital would be alerted to their patients’ admissions for heart attack or heart failure — if those patients had that connection beforehand.
Timely follow-up care — checking on medications, recommending rehab — has prevention at its heart. Its cost can be a barrier to people on Medicare, but that shouldn’t be the case, Thompson said, based on research showing that financial incentives for patients combined with case management brought many more people into rehab.
Medicare is not free, after all.
“Paying for a cardiac rehab session is far less expensive than paying for a stent,” Thompson said. “As far as I’m concerned, we shouldn’t be making people pay for things that would ultimately save everyone money.”
Patel said the study’s numbers can help chart future policy.
“One thing that I find heartening about these findings is that overall, the absolute change within every demographic strata considered is increasing, in seeing a provider within 30 days,” she said. “When I look at these data, I see that to some extent the widening disparities we’re seeing is not because another group got worse per se, but that the best-off group improved even more.”
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