Rishi K. Wadhera

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among US veterans, many receiving cardiovascular care across both the Veterans Health Administration (VA) and non-VA hospitals, driven in part by the growth of Medicare Advantage (MA) enrollment. With both systems federally financed, overlapping payment responsibilities raise concern for duplicative federal spending on inpatient CVD care. METHODS: We conducted a national, cross-sectional study using 2021 linked MA and VA data to identify CVD hospitalizations defined using diagnosis-related groups among MA-enrolled veterans with VA benefits. Each CVD-related hospitalization (eg, heart failure exacerbation) was categorized by source of payment: MA-paid community hospital care, VA-paid community hospital care, or VA-direct care at VA hospitals. High-veteran plans were defined as ≥20% veteran enrollment. Multinomial logistic regressions were used to evaluate associations between high-veteran MA plan enrollment and payment source, adjusting for patient characteristics and state fixed effects. Analyses were stratified by admission complexity and elective status. RESULTS: Sample included 76 722 MA-enrolled veterans (mean [SD] age, 78.0 [8.8] years, 97.9% male), of which 10 366 (13.5%) were in high-veteran MA plans, and 66 356 (86.5%) were in high-veteran MA plans. Veterans in high-veteran MA plans were less likely to have MA-paid community hospitalizations than those in low-veteran MA plans (43.2% versus 69.2%; –26.1 percentage-points [95% CI, –27.1 to –25.1]) but more likely to have VA-paid community care (28.1% versus 16.0%; +12.2 percentage-points [95% CI, 11.3–13.0]) and VA-direct care (28.7% versus 14.8%; +13.9 percentage-points [95% CI, 13.0–14.8]). Results were consistent across admission types and medical complexity. CONCLUSIONS: Veterans enrolled in high-veteran MA plans were more likely to have inpatient CVD care financed by the VA, suggesting that MA plans may be shifting costs despite receiving capitated payments intended for inpatient care. Policy reforms are needed to reduce duplicative federal spending and improve coordination of cardiovascular care.

BACKGROUND: Cardiovascular disease is highly prevalent among older adults and remains a leading cause of morbidity and mortality in Medicare. Medicare Advantage (MA)—the managed care alternative to traditional Medicare (TM)—offers adults integrated care and supplemental benefits that may improve outcomes and satisfaction for this high-risk population. METHODS: We used longitudinal data from the National Health and Retirement Study (2010–2022) and an event-study, difference-in-differences design to compare changes in self-reported measures of health care access, utilization, affordability, and satisfaction among adults with cardiovascular conditions newly enrolling in MA versus TM (exposure) at 65 years. Eligible adults had a self-reported history of hypertension, diabetes, hyperlipidemia, heart disease, or stroke. RESULTS: A total of 3312 adults with cardiovascular conditions newly enrolled in Medicare, 34.3% in MA (mean age, 63.6 years; 60.5% female) and 65.7% in TM (mean age, 63.5 years; 56.5% female). Following enrollment, there were no differential changes in health care access or utilization between MA and TM at any follow-up time point. However, new MA enrollees experienced relative improvements in affordability compared with their TM counterparts, including greater reductions in trouble affording medical care (difference-in-differences estimate −6.6 percentage points [95% CI, −12.0 to −1.3]) and trouble affording prescription medications (difference-in-differences estimate −4.6 pp [95% CI, −9.2 to −0.2]) by the end of follow-up. Satisfaction with care increased in both groups but with larger gains among MA enrollees (difference-in-differences estimate at the end of follow-up +11.3 pp [95% CI, 5.2–17.4]). CONCLUSIONS: For adults with cardiovascular conditions transitioning into Medicare at 65 years, enrollment in MA was associated with greater improvements in affordability and satisfaction compared with TM. These findings may inform coverage decisions for this high-risk population, though generalizability to older beneficiaries or those with more advanced disease remains uncertain.

Introduction: The COVID-19 pandemic led to significant disruptions in cardiovascular care and reductions in physical activity, but little is known about how exercise patterns changed after this period. This study assessed changes in weekly aerobic and strength training activity between 2020 and 2022 amongst adults aged 18 years or older who reported one or more cardiovascular diseases or risk factors. Methods: This study used National Health Interview Survey data from 2020 and 2022. Adjusted differences for moderate-to-vigorous physical activity (MVPA) were calculated using a linear regression model and for strength sessions using a Poisson regression, adjusting for sex and age. Changes in these outcomes were then stratified by age and sex subgroups. Results: The weighted study population included 182,783,008 (standard error, ±3,334,337) adults in 2020 and 185,388,060 (SE, ±3,285,161) adults in 2022. Between 2020 and 2022, the overall weekly MVPA increased from 244.2 (SE, ±4.5) minutes to 266.3 (SE, ±5.7) minutes (adjusted difference, +22.1 [SE, ±6.92] minutes). There were no statistically significant changes in the number of strength session per week overall or among sex and age subgroups. Across sex and age subgroups, increases in weekly MVPA were entirely concentrated among males and younger adults. Conclusion: The recovery from pandemic era reductions in aerobic and strength exercise training was uneven amongst demographic subgroups, which aligns with concurrent persistent disruptions in cardiovascular care.

BACKGROUND: Over half of Medicare beneficiaries are enrolled in privately administered Medicare Advantage (MA) plans, and aortic stenosis predominantly affects older patients. In this study, we evaluated whether differences in care delivery between MA and fee-for-service (FFS) Medicare contribute to cardiovascular outcomes after transcatheter aortic valve replacement (TAVR). METHODS: Medicare patients who underwent TAVR from January 1, 2018, to December 31, 2022, were eligible for cohort inclusion. TAVR utilization rates in MA and FFS were calculated as the age- and sex-standardized number of procedures per 10 000 person-years. Patient characteristics were compared between MA and FFS using standardized mean differences (SMDs), with an SMD ≥10 considered meaningful. The association of MA versus FFS enrollment with 30-day and 1-year outcomes was assessed using logistic and Cox regression models, respectively. RESULTS: Among the 317 630 patients (64.4% FFS, 35.6% MA) undergoing TAVR, the mean age was 80.6±7.0 years, and 55.1% were male. TAVR utilization rates were similar between MA and FFS, with 11.2 TAVRs/10 000 person-years in FFS compared with 11.7 TAVRs/10 000 person-years in MA by the end of the study. Compared with FFS patients, MA patients were more likely to be Black (5.4% versus 3.0%; SMD, −11.9) and dual-enrolled in Medicaid (13.7% versus 8.6%; SMD, −16.3). Comorbidity profiles were similar (SMD, < 10). In the comorbidity-adjusted model, MA patients had lower odds of 30-day death (adjusted odds ratio, 0.90 [95% CI, 0.86–0.95]). At 1 year, MA patients had a lower adjusted risk of death (hazard ratio, 0.94 [95% CI, 0.92–0.96]), all-cause readmission (hazard ratio, 0.86 [95% CI, 0.85–0.88]), stroke (hazard ratio, 0.90 [95% CI, 0.87–0.94]), and aortic valve reintervention (hazard ratio, 0.86 [95% CI, 0.76–0.96]). CONCLUSIONS: Despite similar clinical profiles and TAVR utilization, MA patients appeared to experience better 30-day and 1-year outcomes than FFS patients. Differences in care delivery may contribute, but future studies are needed to understand differences in outcomes.

Background: Although the availability of electrophysiology technologies has expanded in the United States, little is known about how sociodemographic factors influence their use. This national study of the Medicare population aims to (1) examine trends in the use of contemporary electrophysiology procedures and (2) assess associations between sociodemographic factors and population‐level use of these procedures. Methods: We identified Medicare beneficiaries who underwent pulmonary vein isolation, left atrial appendage occlusion, leadless pacemaker implantation, or subcutaneous implantable cardioverter‐defibrillator implantation from 2018 to 2021 using Current Procedural Terminology codes. Procedural rates were calculated per 100 000 person‐years among all eligible Medicare beneficiaries. We compared the rates of each procedure across sociodemographic characteristics (including sex, race, census region, and social vulnerability index) by reporting rate ratios adjusted for age and comorbidities. Results: A total of 425 242 electrophysiology procedures performed between 2018 and 2021 were included. During the study period, use rates of pulmonary vein isolation, left atrial appendage occlusion, and leadless pacemaker increased steadily, whereas subcutaneous implantable cardioverter‐defibrillator use declined. In adjusted models, individuals identifying as Black or categorized as other race were less likely to undergo a pulmonary vein isolation, left atrial appendage occlusion, and leadless pacemaker procedure but were more likely to receive a subcutaneous implantable cardioverter‐defibrillator. Beneficiaries in less socially vulnerable areas were more likely to receive pulmonary vein isolation, left atrial appendage occlusion, and leadless pacemaker but less likely to undergo subcutaneous implantable cardioverter‐defibrillator implantation. Regional variation showed higher use rates in the South and West of the United States. Conclusions: Significant sociodemographic differences in the use of contemporary electrophysiology procedures persist across communities in the United States. Targeted efforts are needed to ensure that use aligns with clinical need.

Background: Cardiovascular mortality has worsened among rural adults compared with urban counterparts over recent decades. Medicare Advantage (MA) enrollment is increasing in rural areas, yet its impact on access and affordability for high‐risk cardiovascular populations remains unclear. This study evaluated differences in health care access, preventive care, and affordability barriers between rural adults with cardiometabolic conditions enrolled in MA versus traditional Medicare. Methods: A cross‐sectional analysis was performed using 2021 to 2022 Medicare Current Beneficiary Survey data. Multivariable logistic regression was used to estimate adjusted risk differences (aRD) in access, preventive care, and affordability barriers between rural MA and traditional Medicare enrollees, adjusting for sociodemographic characteristics. Results: The study included 4274 rural beneficiaries with cardiometabolic conditions (weighted population 16 352 800, 53% women). Compared with traditional Medicare, MA enrollees were significantly less likely to miss an annual wellness visit (40.1% versus 50.1%; aRD, −13.4% [95% CI, −17.0% to −9.8%]) or face barriers to preventive care, such as not having annual cholesterol checks (aRD, −3.2% [95% CI, −5.2% to −1.2%]) and influenza vaccinations (aRD, −4.3% [95% CI, −7.8% to −0.7%]). However, MA beneficiaries were more likely to have problems paying medical bills (12.2% versus 6.9%; aRD, 2.5% [95% CI, 0.4%–4.6%]). Conclusions: Rural MA beneficiaries with cardiometabolic conditions experienced fewer barriers to preventive care but reported greater difficulty paying medical bills than those in traditional Medicare. As MA expands in rural America, policies are needed to address affordability challenges while preserving access to preventive services.