Hospitalizations and Mortality Among Medicare Beneficiaries at Cardiovascular Risk

BACKGROUND: The COVID-19 pandemic led to disruptions in cardiovascular care in mid-2020, but less is known about how patterns of care and clinical outcomes changed for older adults with cardiovascular (CV) risk factors and/or established cardiovascular disease (CVD) in the later stages of the pandemic. OBJECTIVES: This study sought to identify changes in utilization of health care services and all-cause mortality among Medicare beneficiaries with CV risk factors or CVD in the "late pandemic" (January 2021 to December 2022) overall and across subgroups based on rurality and social vulnerability index. METHODS: The study included all Medicare fee-for-service and Medicare Advantage beneficiaries with CV risk factors (hypertension, diabetes mellitus, hyperlipidemia) or CVD (coronary heart disease, heart failure, atrial fibrillation, stroke) from January 2018 to December 2022. A Poisson-lognormal regression model was fitted to compare the adjusted incidence rate ratio (aIRR) of acute care visits, outpatient visits, and all-cause mortality during the late pandemic (January 2021 to July 2022) compared with the prepandemic period (January 2018 to December 2019). RESULTS: There were 51,355,577 beneficiaries in the prepandemic period and 55,214,638 in the late pandemic period with CV risk factors or CVD. Hospital visit rates were lower in the late pandemic period compared with the prepandemic period (aIRR: 0.918; 95% CI: 0.915-0.922), and declines were evident among rural and urban beneficiaries, as well as across all levels of social vulnerability and in both fee-for-service and Medicare Advantage. In contrast, use of outpatient visits was higher during the late pandemic period (aIRR: 1.141; 95% CI: 1.134-1.149); these increases were on average higher among urban communities and Medicare Advantage beneficiaries. Mortality was higher during the late pandemic period (aIRR: 1.248; 95% CI: 1.240-1.257), and surges in mortality among this population tracked with national COVID-19 mortality. Beneficiaries in the most socially vulnerable communities (aIRR: 1.116; 95% CI: 1.106-1.124) and those covered by Medicare Advantage (aIRR: 1.342; 95% CI: 1.329-1.356]) experienced the greatest increase. CONCLUSIONS: In the later stages of the COVID-19 pandemic, among Medicare beneficiaries with CV risk factors or established CVD, hospitalizations were lower than before the pandemic, outpatient care was used more frequently, and mortality was significantly elevated across risk groups and geographies, with the greatest increases seen in vulnerable communities and those covered by Medicare Advantage.