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Decline in hospitalizations for heart attack and stroke persisted through 2020

JAMA Cardiology
Reuters Health - 05/08/2021 - During the early months of the COVID-19 pandemic, hospitalizations for stroke and myocardial infarction dropped sharply, and never recovered completely, remaining about 12% below previous years through the second half of 2020, a new study finds.

An analysis of data from the Medicare Beneficiary Summary File from 2018 through 2020 revealed that hospital use for acute myocardial infarction (AMI) and stroke was 14% lower overall in 2020 compared with 2018 and 2019. Rates plummeted 32% in March and April during the pandemic's initial wave and lockdowns, then began a partial recovery, although it's unclear why the rates remained below average through year-end, according to the report published in JAMA Cardiology.

"Our study shows a large decline in hospital use for heart attacks and strokes in the spring of 2020 among fee for service Medicare beneficiaries," said the study's lead author, Kate Stewart, a principal researcher at Mathematica, a public policy research organization for the public and private sectors.

"This raises concerns that patients were not seeking care for these types of medical emergencies," Stewart said. "Because we only have claims data, we don't know for certain why there was a decline. Obviously, this is an avenue for future research."

Stewart says she and her colleagues decided to look into the issue after reading other studies that looked at younger patients and reported declines in hospital use for a broad range of conditions. "It made us wonder if we would see similar patterns among the Medicare population," she said.

Stewart and her colleagues used the Medicare Beneficiary Summary File to identify all beneficiaries enrolled in Medicare fee for service since 2018. The researchers then put together a beneficiary week-level file with demographic and enrollment characteristics and an indication of whether beneficiaries' claims data were observable that week because they were alive and still enrolled at the start of the week.

For each observable week, Stewart and her colleagues used inpatient and outpatient claims to identify hospitalizations, outpatient emergency department visits, and observation stays with a diagnosis code for new AMI or stroke, including transient ischemic attacks.

For each week, they calculated the unduplicated number of new AMI and stroke events per 100,000 beneficiaries. They then compared weekly rates in 2020 versus the mean rate for the same weeks across 2018 and 2019. They repeated their analyses for subgroups, such as gender, race, Medicaid dual-eligibility status, and certain chronic conditions.

Across 2018 and 2019, Medicare beneficiaries averaged 43 hospitalizations, outpatient emergency department visits, or observation stays for AMI and stroke per 100,000 beneficiaries per week. Over all weeks, hospital use for AMI and stroke was 14% lower in 2020 than 2018 and 2019, with an especially large (mean 32%) decline between weeks 11 and 14 (March 11 to April 7, 2020).

Between weeks 15 and 25, hospital use for AMI and stroke began increasing toward 2018 and 2019 levels, but 2020 weekly rates remained 12% lower, on average, between weeks 26 and 52 compared with the same weeks in 2018 and 2019.

That's despite a recovery in total Medicare spending over the same period, which suggests many beneficiaries had stopped avoiding care by mid-2020, the study team notes.

The sharp decline and partial recovery seen in 2020 was similar across the subgroups. However, the greatest overall decline in hospital use for AMI and stroke was seen in the subgroup with six or more chronic conditions, both in absolute terms (a decrease of 30 events per 100,000 beneficiaries per week) and relative terms (a 42% decrease). In contrast, this subgroup had the highest rate of hospital use for AMI and stroke in 2018 and 2019 (approximately 71 per 100,000 beneficiaries).

"As time has passed, we have been able to learn more about the trends of patients seeking care during the early phase of the COVID 19 pandemic," said Dr. Megan Kamath, an assistant clinical professor of medicine at the David Geffen School of Medicine of the University of California, Los Angeles, and an advanced heart failure fellow with UCLA Health.

The results of the current study "could be related to a combination of factors: 1) the possibility of fewer AMI and strokes due to lifestyle and behavior modifications 2) fear of COVID 19 driving patients to avoid seeking care and 3) COVID19 mortality. Further review will be needed to understand these factors and how this will influence healthcare delivery moving forward," Dr. Kamath told Reuters Health by email.

SOURCE: https://bit.ly/37nybLm JAMA Cardiology, online August 4, 2021.

By Linda Carroll

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