Risk-standardized 30-day mortality was lower for patients hospitalized with heart failure (HF) at safety-net hospitals (SNHs), as compared to non-safety-net hospitals (non-SNHs), but similar for stroke, and higher for acute myocardial infarction (AMI) between 2016 and 2019, according to a study that will be presented during AHA 2021 and published simultaneously in the Journal of the American College of Cardiology.

Michael Liu, MPhil, and colleagues, used Centers for Medicare and Medicaid Services (CMS) hospital data for Medicare fee-for-service beneficiaries treated acutely for AMI, HF and stroke from fiscal year 2010 and fiscal year 2020. They also obtained performance data on a new patient-centered performance measure called the excess days in acute care (EDAC), which characterizes the difference between the average observed number of days patients spend in acute care per 100 discharges and the expected number of days given the case mix of the hospital.

The EDAC was developed by CMS in response to criticism that SNHs are unfairly penalized in studies looking at readmissions and outcomes because they treat, on average, sicker patients than non-SNHs. According to the authors, SNHs are important providers of health care services in the U.S. because they provide essential care to any patient, regardless of insurance coverage, ability to pay, or immigration status. However, compared to non-SNHs, these hospitals have been found to perform worse on a wide range of process and outcome measures for cardiovascular conditions, including 30-day mortality and readmissions.

The investigators sought to determine whether changes in federal policies under the Affordable Care Act (ACA), namely the Hospital Readmissions Reduction Program (HRRP) and the Value-Based Purchasing Program, had an impact on outcomes for SNHs compared to non-SNHs.

Results showed that SNHs were more likely to be larger facilities, teaching hospitals, under public ownership and located in rural areas, compared to non-SNHs.

In addition, the 30-day risk-standardized mortality rates were modestly higher for AMI (12.8% vs. 12.6%; adjusted difference, 0.15%; 95% confidence interval [CI], 0.04 to 0.26%), and lower for HF (10.9% vs. 11.5%; adjusted difference, –0.49%; 95% CI, –0.65% to –0.33%), and similar for stroke (13.7% vs. 13.5%; adjusted difference, 0.0%; 95% CI, –0.16% to 0.16%).

The safety-net facilities, however, performed markedly worse on EDAC measures for AMI (15.2 vs. 3.4 excess days) and HF (14.1 vs. 3.9 excess days; both p<0.05) and had significantly higher average EDAC values compared to non-SNHs for both AMI and HF.

The results, say the authors, suggest that progress has been made in improving outcomes for some but not all cardiovascular conditions in the ACA era. "Notably, gains by SNHs have occurred despite these sites having fewer resources and caring for more medically and socially vulnerable patient populations," write Liu and colleagues. The "persistently higher AMI mortality rates at SNHs" are an area of concern and should be targeted for improvement.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: AHA Annual Scientific Sessions, American Heart Association, AHA21, Patient Protection and Affordable Care Act, Patient Readmission, Centers for Medicare and Medicaid Services, U.S., Value-Based Purchasing, Fee-for-Service Plans, Safety-net Providers, Confidence Intervals, Emigration and Immigration, Medicare, Stroke, Diagnosis-Related Groups, Heart Failure, Myocardial Infarction, Cardiology, Patient-Centered Care, Outcome Assessment, Health Care

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