Disparities seen in postdischarge care for Medicaid beneficiaries

Medicaid patients with diabetes who are hospitalized for heart failure may not receive appropriate follow-up after discharge, a recent study found.

Guidelines recommend that all patients receive follow-up care 7 to 14 days after a heart failure hospitalization. To examine rates of such follow-up in a low-income population, researchers analyzed claims in the 60 days after discharge for 9,859 Medicaid-covered adults with diabetes and a first heart failure hospitalization in Alabama. Data were included from 2010 to 2019. The primary outcome was postdischarge visits to primary care (including internal medicine, family medicine, general practitioner, or nurse practitioner), cardiology, or endocrinology. The study results were published June 7 by the Journal of the American Heart Association.

The mean age of the study sample was 53.7 years, 47.3% were Black, 41.8% were non-Hispanic White, 10.9% were Hispanic/Other, and 65.4% were women. Most patients (92.4%) were on Medicaid due to disability compared with 7.6% due to poverty. Overall, 26.7% had an ambulatory care visit within 0 to 7 days, 15.2% within 8 to 14 days, and 31.3% within 15 to 60 days; 26.8% had no visit. Of those who did have an ambulatory care visit, 71% saw a primary care physician and 12% saw a cardiologist. Black and Hispanic/Other adults were less likely to have any postdischarge ambulatory care visit (P<0.0001), were more likely to have a late visit (delayed by 1.8 days [P=0.0006] and 2.8 days [P=0.0016], respectively), and were less likely to see a primary care physician (adjusted incidence rate ratio, 0.96 [95% CI, 0.91 to 1.00] and 0.91 [95% CI, 0.89 to 0.98], respectively) than non-Hispanic White adults.

The researchers noted that they could not obtain data on such factors as heart failure severity or cardiac biomarkers and that their study was done only in Alabama, among other limitations. They concluded that guideline-recommended postdischarge care is often lacking for Medicaid beneficiaries with diabetes and heart failure and that such care varies by race/ethnicity, likely reflecting structural racism and implicit bias. “There is an urgent need for improving postdischarge follow-up for patients with diabetes and HF [heart failure] in the low-income population in Alabama,” the authors wrote. They pointed out that postdischarge care may be improved by engaging in early team-based discharge planning, scheduling an appointment within seven days at the heart failure clinic before discharge, and having a nurse or care coordinator make a reminder call to the patient within 48 hours of discharge.

“Another potential avenue for improving care for patients with diabetes and HF from low-income areas is Medicaid expansion. Medicaid expansion in other states has been associated with higher rates of prescription of guideline-directed medical therapy for HF and newer diabetes medications, including sodium-glucose co-transporter 2 inhibitors,” the authors wrote. Alabama has not expanded Medicaid eligibility under the Affordable Care Act, leaving about 200,000 adults who would be eligible under expansion uninsured, they noted.