Outcomes after peripheral artery disease intervention among Medicare–Medicaid dual-eligible patients compared with the general medicare population in the Vascular Quality Initiative registry

Abstract

ObjectiveTo determine whether patients from the Vascular Quality Initiative (VQI) registry who are Medicare–Medicaid dual-eligible have outcomes after surgical intervention with medical devices such as stents for peripheral artery disease comparable to the outcomes of those eligible for Medicare alone.MethodsThe study cohort included fee-for-service Medicare beneficiaries from 2010 to 2015 who underwent peripheral vascular intervention as determined by the VQI. We performed propensity matching between the dual-eligible and non-dual-eligible cohorts. Postintervention use, including imaging, amputation and death, was determined using Medicare claims data.ResultsRates of major amputation were higher among dual-eligible patients (13.0% vs 10.5%, p<0.001), while time to amputation by disease severity was similar (p=0.443). For patients with more advanced disease (critical limb ischaemia (CLI) vs claudication), dual-eligible patients have significantly faster times to any amputation and death (p<0.001). For of postoperative imaging, 48.4% of dual-eligible patients receive at least one postoperative image, while the percentage for non-dual-eligible patients is 47.2% (p=0.187).ConclusionsPatients with mild forms of peripheral artery disease (PAD), such as claudication, demonstrated similar outcomes regardless of dual-eligibility status. However, those with severe PAD, such as CLI, who were also dual-eligible had both inferior overall survival and amputation-free survival. Minimal differences were observed in process-driven aspects of care between dual-eligible and non-dual-eligible patients, including postoperative imaging. These findings indicate that despite receiving similar care, dual-eligible patients with severe PAD have inferior long-term outcomes, suggesting the Medicaid safety net is not timely enough to benefit from long-term outcomes for these patients.

Association of Dual Medicare and Medicaid Eligibility With Outcomes and Spending for Cancer Surgery in High-Quality Hospitals

“…Dual eligibility status has previously been shown to be a more powerful marker of social risk and poor outcomes than other factors, such as race and ethnicity and neighborhood factors . Our results are consistent with previous research that has shown poorer outcomes in DE patients . Higher rates of complications and nonhome discharge have important implications for DE patients undergoing cancer treatment because previous research has shown these are risk factors for delayed chemotherapy and worse survival .…”

“…12 Our results are consistent with previous research that has shown poorer outcomes in DE patients. [7][8][9][10][11] Higher rates of complications and nonhome discharge have important implications for DE patients undergoing cancer treatment because previous research has shown these are risk factors for delayed chemotherapy and worse survival. [32][33][34] However, our analysis builds on these findings by examining the role of hos-pital quality in mitigating these disparities.…”

“…2,3 Furthermore, DE patients have been shown to have higher service use and higher spending. [4][5][6] Dually eligible patients are also known to have worse adherence to cancerspecific process measures across different specialties, [7][8][9][10] including lower receipt of recommended radiotherapy or chemotherapy in breast, endometrial, and colon cancer and lower likelihood of adequate lymph node harvest in gastric cancer. 11 Given these factors, DE patients represent a highly marginalized population, with social determinants of health contributing to adverse outcomes and increased use of health care services.…”

Trends of Concomitant Diabetes and Peripheral Artery Disease and Lower Extremity Amputation in US Medicare Patients, 2007 to 2019

“…An overall model considering age, sex, race, Medicare-Medicaid dual-eligibility status, and HRR location demonstrated a direct relationship between the risk of amputation and the rate of diabetes and PAD among all Medicare beneficiaries (odds ratio, 3.24 [95% CI, 3.27–3.25]). 15…”

Healthcare: not sufficiently powerful to correct underlying causes of poor outcomes if delivered too late

“…The study by Andrea Austin and colleagues, which compares the outcomes of patients with peripheral artery disease in receipt of Medicare and Medicaid with those who only receive Medicare, highlights two important associations between poverty and health. 1 The first is that poverty can have an enduring effect on health outcome. The second is that Tudor Hart’s observation in 1971 that ‘the availability of good medical care tends to vary inversely with the need for it in the population served’ still holds.…”