Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ.
Department of Biostatistics and Bioinformatics, Duke University, Durham, NC.
Am Heart J. 2022 Feb;244:135-148. doi: 10.1016/j.ahj.2021.11.011. Epub 2021 Nov 20.
Uninsurance is a known contributor to racial/ethnic health inequities. Insurance is often needed for prescriptions and follow-up appointments. Therefore, we determined whether the Affordable Care Act(ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment(GDMT) at discharge among patients hospitalized with heart failure(HF) by race/ethnicity.
Using Get With The Guidelines-HF registry, logistic regression was used to assess odds of receiving GDMT(HF medications; education; follow-up appointment) in early vs non-adopter states before(2012 - 2013) and after ACA Medicaid Expansion(2014 - 2019) within each race/ethnicity, accounting for patient-level covariates and within-hospital clustering. We tested for an interaction(p-int) between GDMT and pre/post Medicaid Expansion time periods.
Among 271,606 patients(57.5% early adopter, 42.5% non-adopter), 65.5% were White, 22.8% African American, 8.9% Hispanic, and 2.9% Asian race/ethnicity. Independent of ACA timing, Hispanic patients were more likely to receive all GDMT for residing in early adopter states compared to non-adopter states (P <.0001). In fully-adjusted analyses, ACA Medicaid Expansion was associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients [before ACA:OR 0.40(95%CI:0.13,1.23); after ACA:OR 2.46(1.10,5.51); P-int = .0002], but this occurred in the setting of an immediate decline in prescribing patterns, particularly among non-adopter states, followed by an increase that remained lowest in non-adopter states. The ACA was not associated with receipt of GDMT for other racial/ethnic groups.
Among GWTG-HF hospitals, Hispanic patients were more likely to receive all GDMT if they resided in early adopter states rather than non-adopter states, independent of ACA Medicaid Expansion timing. ACA implementation was only associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients. Additional steps are needed for improved GDMT delivery for all.
没有保险是导致种族/民族健康不平等的已知因素。保险通常是开处方药和预约后续治疗所必需的。因此，我们确定了《平价医疗法案》（ACA）医疗补助扩大范围是否与心力衰竭（HF）住院患者种族/民族出院时接受指南指导的医疗治疗（GDMT）的比例增加有关。
使用 Get With The Guidelines-HF 登记处，使用逻辑回归评估每个种族/民族内，在 ACA 医疗补助扩大之前（2012-2013 年）和之后（2014-2019 年），在早期和非早期采用者州内接受 GDMT（HF 药物；教育；后续预约）的可能性，同时考虑患者水平的协变量和院内聚类。我们测试了 GDMT 和医疗补助扩大之前/之后时间之间的交互作用（p-int）。
在 271606 名患者（57.5%为早期采用者，42.5%为非早期采用者）中，65.5%为白人，22.8%为非裔美国人，8.9%为西班牙裔，2.9%为亚洲人。独立于 ACA 时间，与非采用者州相比，西班牙裔患者更有可能因居住在早期采用者州而接受所有 GDMT（P <.0001）。在完全调整的分析中，ACA 医疗补助扩大与西班牙裔患者接受 ACEI/ARB/ARNI 的可能性增加相关[ACA 前：OR 0.40（95%CI：0.13，1.23）；ACA 后：OR 2.46（1.10，5.51）；p-int=0.0002]，但这是在处方模式立即下降的情况下发生的，特别是在非采用者州，随后增加，但在非采用者州仍然最低。ACA 与其他种族/民族接受 GDMT 无关。
在 GWTG-HF 医院中，如果西班牙裔患者居住在早期采用者州，而不是非采用者州，则更有可能接受所有 GDMT，而与 ACA 医疗补助扩大的时间无关。ACA 实施仅与西班牙裔患者接受 ACEI/ARB/ARNI 的可能性增加相关。需要采取更多措施来改善所有人的 GDMT 治疗。
