The Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) program is a Medicare Alternative Payment Model that launched in January 2023, based on the Global and Professional Direct Contracting Model that preceded it. The transition from that program to ACO REACH was unique in the Medicare portfolio in its focus on health equity and emphasis on capitated payments. We found that in the first year of ACO REACH, 132 participating ACOs cared for more than two million Medicare beneficiaries. Nearly nine in ten ACOs met quality cutoffs for Continuous Improvement/Sustained Exceptional Performance bonuses. The average Medicare spending benchmark was approximately $16,000 per beneficiary, and nearly three-quarters of participants had spending that was lower than their benchmark. ACOs with more experience and those with a higher proportion of medically complex beneficiaries (and thus higher benchmarks) had greater savings than newer ACOs and those with lower benchmarks.

Introduction: The coronavirus 2019 pandemic disrupted medical care delivery for cerebrovascular disease. Little is known about the long-term changes in healthcare utilization and mortality among people who suffered cerebrovascular events. Methods: We used 2018-2022 data to identify all Medicare fee-for-service and Medicare Advantage beneficiaries with a diagnosis code for an acute cerebrovascular event (stroke, transient ischemic attack, hemorrhage). We used Poisson-lognormal regression models with an offset term (beneficiary years) to model incident rate ratios (IRR) for late COVID (2021-2022) versus pre-COVID (2018-2019) for outpatient visits, emergency department (ED) visits, hospitalizations, and mortality in the year following the index event, adjusting for age, sex, and race. We examined patterns overall and by rurality (urban, micropolitan, rural) and quartile (q) of social vulnerability index. Results: We identified 7,071,072 and 7,065,171 unique beneficiaries in the pre-COVID and late-COVID periods, respectively, with an acute cerebrovascular event. Our cohort was predominantly non-Hispanic white (73%), female (54%), and urban (83%). Compared to pre-COVID, outpatient care utilization in the year following the acute event was higher in 2021-2022 (IRR = 1.14, 95% confidence interval [CI]: 1.13-1.14), while ED visits (IRR = 0.92, 95% CI: 0.91-0.92) and inpatient hospitalizations (IRR = 0.94, 95% CI: 0.94-0.95) were lower. Mortality was higher during the late-COVID versus pre-COVID period (IRR = 1.24, 95% CI: 1.23-1.25). The mortality differences were similar across rural strata but higher in more socially disadvantaged areas (IRR 1.20, 1.22, 1.24, 1.27 for q1 [reference], p interaction = q2 = 0.12, q3 = 0.01, and q4 < 0.001). Conclusions: Medicare beneficiaries who sustained acute cerebrovascular events had marked differences over the subsequent year in healthcare utilization patterns and increased mortality in the late-COVID period compared with their utilization and outcomes pre-COVID. The differences in mortality were the most pronounced for beneficiaries in socially disadvantaged areas.

BACKGROUND:Current guidelines do not recommend transcatheter aortic valve replacement (TAVR) in adults aged <65 years with isolated aortic stenosis and a life expectancy >10 years. METHODS:This retrospective cohort study was conducted using the Vizient Clinical Database in adults aged <65 years with isolated aortic stenosis who underwent aortic valve replacement (AVR) with a bioprosthetic valve between 2018 and 2023. Hospital-level variation in TAVR vs surgical AVR (SAVR) was evaluated using multilevel multivariable logistic regression. RESULTS:Among 13,907 AVRs, 6142 (44.2%) were SAVR, and 7,765 (55.8%) were TAVR. The median hospital TAVR rate was 52.9% (interquartile range, 35.3%-70.7%). Among patients at the lowest surgical risk (predicted mortality <0.5%), 46.5% underwent TAVR. Patients treated at hospitals with higher risk-adjusted TAVR vs SAVR use had a 2.7-fold higher odds of undergoing TAVR than patients treated at hospitals with a lower risk-adjusted rate (median odds ratio, 2.69; 95% CI 2.43-3.02). Lower-volume hospitals (based on total AVR volume [SAVR plus TAVR]) performed fewer TAVRs vs SAVRs compared with higher-volume hospitals. Teaching status, Disproportionate Share Hospital Percentage, rurality, and average daily census were not significantly associated with TAVR use. CONCLUSIONS:Substantial variation exists in hospital rates of TAVR vs SAVR among patients aged <65 with isolated aortic stenosis, even after adjusting for patient characteristics. Nearly half of the lowest-risk patients (mortality <0.5%) aged <65 underwent TAVR instead of SAVR. These findings suggest that practice patterns and nonclinical factors may influence procedure selection in this population.

Importance:During early months of the COVID-19 pandemic, presentations for acute myocardial infarction (AMI) declined significantly, and outcomes worsened. However, the full extent and long-term sequelae of changes in AMI epidemiology during the pandemic remain uncertain, as does whether these patterns differed by rurality. Objective:To describe the epidemiology of AMI-related hospitalizations, interventions, and outcomes among Medicare beneficiaries throughout the COVID-19 pandemic, focusing on differences in urban and rural populations. Design, Setting, and Participants:This retrospective cohort study included all Medicare fee-for-service beneficiaries with AMI between January 1, 2018, and December 31, 2023, in the analysis. Data were analyzed from March 19 to July 9, 2025. Exposures:Time period (prepandemic [January 1, 2018, to December 31, 2019], pandemic [January 1, 2020, to December 31, 2021], and postpandemic [January 1, 2022, to December 31, 2023]) and beneficiary-level rurality. Main Outcomes and Measures:The primary outcome was in-hospital death, defined as death within 1 day of discharge from the index episode of AMI. Secondary outcomes included death within 90 days of the index admission date and postdischarge outcomes. AMI episodes were defined as any emergency department (ED), observational, or inpatient stay with a primary ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) diagnosis or a primary cardiogenic shock and secondary STEMI or NSTEMI diagnosis. Generalized estimating equations clustering on hospitals were used to compare pandemic and postpandemic outcomes with the prepandemic period, adjusting for beneficiary characteristics. Results:A total of 1 152 851 AMI episodes among 1 032 212 beneficiaries were identified between 2018 and 2023, of which 75.6% were NSTEMI. Most AMI episodes were among male (57.6%) beneficiaries aged 65 to 80 years (56.8%). The unadjusted quarterly incidence of AMI decreased from 17.2 to 13.0 episodes per million beneficiary days at risk (quarter 1 of 2018 to quarter 4 of 2023). In-hospital (adjusted odds ratio [AOR], 1.09; 95% CI, 1.07-1.11]) and 90-day mortality (AOR, 1.10; 95% CI, 1.09-1.12) increased during the pandemic and then returned to baseline or lower (AORs, 0.99 [95% CI, 0.97-1.01] and 0.96 [95% CI, 0.95-0.98], respectively). After the pandemic, beneficiaries were less likely to discharge to a skilled nursing facility (AOR, 0.67; 95% CI, 0.66-0.68), utilize the ED (adjusted incidence rate ratio [AIRR], 0.93; 95% CI, 0.92-0.94), or experience readmission (AIRR, 0.90; 95% CI, 0.90-0.92) within 90 days of their index episode of AMI. Patterns were largely similar by rurality. Conclusions and Relevance:In this retrospective cohort study of fee-for-service Medicare beneficiaries, the incidence of AMI decreased during and after the pandemic. Beneficiaries experienced greater in-hospital and 90-day mortality during the pandemic. After the pandemic, in-hospital and 90-day mortality returned to baseline among micropolitan and rural beneficiaries and was lower than baseline among urban beneficiaries.

Aim The "2025 AHA/ACC Statement on Cost/Value Methodology in Clinical Practice Guidelines (Update From 2014 Statement)" describes a systematic approach for consistent implementation of "economic value statements" across ACC/AHA guidelines. It updates the cost-effectiveness threshold and proposes a new level of certainty framework that summarizes the strength of the available evidence. Additionally, it describes how cost-effectiveness analyses (CEAs) can help advance equity in population cardiovascular health. Methods A focused literature search was conducted from January 9, 2024, to February 2, 2024, encompassing English-language publications related to CEA methodology in PubMed, EMBASE, and the Cochrane Library, with publication dates ranging from 1973 to the present. Additional relevant studies published during the writing process (through June 25, 2024) were also considered by the writing committee. Structure This Cost/Value Methodology Statement updates prior guidance regarding the incorporation of evidence from published CEAs into clinical guidelines. It provides guidance for identifying and synthesizing relevant high-quality evidence, developing economic value statements, and communicating level of certainty in such statements. It defines the US cost-effectiveness threshold as $120,000 per quality-adjusted life year gained, highlights special considerations related to cardiovascular drugs and devices, emphasizes health equity considerations when interpreting CEAs, and defines a reference case for future CEAs.

BACKGROUND:Forecasts for the future prevalence of cardiovascular disease and stroke are crucial to guide efforts to improve health outcomes across the life course for women. METHODS:Using historical trends from the 2015 to 2020 National Health and Nutrition Examination Survey, 2015 to 2019 Medical Expenditure Panel Survey, and census estimates for population growth, we estimated trends in prevalence through 2050 for cardiovascular risk factors based on suboptimal levels of Life's Essential 8 and clinical cardiovascular disease and stroke, overall and by age and race and ethnicity. RESULTS:Among adult women overall, the prevalence of hypertension is estimated to increase from 48.6% in 2020 to 59.1% in 2050. Diabetes (14.9% to 25.3%) and obesity (43.9% to 61.2%) will increase, whereas hypercholesterolemia will decline (42.1% to 22.3%). Prevalences of suboptimal diet, inadequate physical activity, and smoking will decline over time, and inadequate sleep will increase. Prevalences of coronary disease (6.85% to 8.21%), heart failure (2.45% to 3.60%), stroke (4.14% to 6.74%), atrial fibrillation (1.58% to 2.31%), and total cardiovascular disease and stroke (10.7% to 14.4%) will rise. Similar trends are projected in girls 2 to 19 years of age, with an increase from 19.6% to 32.0% projected in obesity. Most adverse trends are projected to be more pronounced among women and girls identifying as American Indian/Alaska Native or multiracial, Black, or Hispanic. CONCLUSIONS:The prevalence of cardiovascular risk factors and disease in women and girls will increase over the next 30 years. Focused clinical and public health interventions are needed across the life course to address these adverse trends.

OBJECTIVE:To assess the association between skilled nursing facility (SNF) utilization and Alzheimer's disease and related dementias (ADRD) both before and during the COVID-19 pandemic. DESIGN:A retrospective longitudinal study. SETTING AND PARTICIPANTS:The study included community-dwelling respondents aged 65 or older. METHODS:This study analyzed data from 3 waves of the Health and Retirement Study and employed multivariable, individual-level regressions. The primary outcomes were any SNF stays, the number of SNF stays, and the total number of SNF days, in the past 2 years of the survey, determined retrospectively based on self-report or proxy reports. Respondents were classified as cognitively healthy, having cognitive impairment but not dementia (CIND), or having ADRD. RESULTS:The study included 23,654 observations, representing 14,914 unique respondents. Before the pandemic, differences in any SNF stays, and the number of SNF stays between the cognitively healthy and CIND and ADRD groups were statistically insignificant in multivariable regressions. During the pandemic, compared with respondents who were cognitively healthy, those with CIND had higher odds of any SNF stays (odds ratio [OR], 1.53; 95% CI, 1.06-2.20) and more SNF stays (incidence rate ratio [IRR], 2.40; 95% CI, 1.30-4.40); similarly, the ADRD group showed higher odds of any SNF stays (OR, 1.68; 95% CI, 1.08-2.59) and more SNF stays (IRR, 2.48; 95% CI, 1.36-4.47) than cognitively healthy older adults. The total number of SNF days for CIND and ADRD respondents remained statistically insignificantly different from those of the cognitively healthy group, both before and during the pandemic, in regression analyses. CONCLUSIONS AND IMPLICATIONS:This cohort study suggests that the pandemic was associated with increased differences in any SNF stays and number of transitions to SNFs between cognitively healthy individuals and those with CIND or ADRD. These findings provide a foundation for understanding the potential impact of a public health emergency on post-acute care utilization among older adults with varying degrees of cognitive impairment.

Importance:There were well-documented changes in health care use during the COVID-19 pandemic. Little is known about whether there were any associated decreases in claims-based comorbidity ascertainment that might have relevance to health services and policy research. Objective:To quantify differences in claims-based comorbidity assessment in Medicare beneficiaries pre- vs post-COVID-19. Design, Setting, and Participants:This cross-sectional study analyzed data from the 30 Chronic Conditions Warehouse 1- or 2-year lookback claims algorithms to ascertain each comorbidity with exact date ranges for all fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries. Data were analyzed from April 2025 to April 2026. Exposures:The first quarter (Q1) of 2019 and 2022 were evaluated as pre- and post-COVID-19, respectively. Main Outcomes and Measures:The main outcomes were comorbidities per beneficiary and association between each comorbidity and mortality in 2019 vs 2022. The changes in prevalence of each comorbidity between 2019 and 2022 were analyzed and fit models within disjoint population subgroups were combined via multilevel meta-analysis models to determine whether each comorbidity's association with mortality changed over time. Results:This study included 59 514 042 beneficiaries in 2019 (32 351 732 females [54.4%]; 50 814 834 aged 65 years or older [85.4%]) and 63 202 599 beneficiaries in 2022 (34 377 560 females [54.4%]; 55 197 435 aged 65 years or older [87.3%]). The mean number of coded comorbidities per beneficiary decreased from 3.85 to 3.62 for FFS and 4.54 to 4.39 for MA (-0.15) between 2019 and 2022. In FFS, 19 comorbidities (63.3%) decreased, 2 (6.7%) were unchanged, and 9 (30%) increased. In MA, 14 comorbidities (46.7%) decreased, 7 (23.3%) were unchanged, and 9 (30%) increased. In multivariable analyses pooled across FFS and MA, 11 comorbidities (36.7%) were more positively associated with mortality, and 4 (13.3%) were more negatively associated with mortality in Q1 2022 than in Q1 2019. Conclusions and Relevance:Coded levels of many comorbidities in Medicare were lower postpandemic than prepandemic, and the association of these codes with mortality changed. This suggests that across the COVID-19 pandemic comorbidity capture was affected by utilization changes, and the association between comorbidities and mortality changed as a result. Analyses that include immediately pre- or post-COVID-19 data and condition inferences on membership in utilization-based disease groups, or use claims-based risk adjustment, may be subject to bias.

OBJECTIVES:Expanded coverage for telehealth during the COVID-19 pandemic allowed providers to bill for telemedicine services that were previously not reimbursable, including telemedicine critical care (TCC) services for critically ill patients. We aimed to characterize TCC billing practices among Medicare beneficiaries before, during, and after the COVID-19 pandemic. DESIGN, SETTING, AND PATIENTS:This was a serial cross-sectional study of adult Medicare Fee-For-Service beneficiaries with at least one bill for critical care at acute care hospitals from January 2018 to September 2024. TCC billing was identified using provider billing codes; multivariate regression models were used to determine characteristics associated with receipt of TCC. Key outcomes were patient-, provider-, and hospital-level characteristics associated with TCC billing. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Billing for TCC increased from 0.002% of critical care bills pre-pandemic to 0.01% of critical care bills during and after the pandemic. Patients billed for TCC were disproportionately likely to have COVID-19 but were otherwise relatively similar to critically ill patients not billed for TCC. Internal medicine/critical care providers accounted for the highest proportion of pandemic TCC bills (46.0%). TCC billing occurred more often at minor teaching hospitals (adjusted odds ratio [aOR], 1.21; 95% CI, 1.03-1.43) and at safety-net hospitals (aOR, 1.33; 95% CI, 1.04-1.70). TCC billing was less likely at small-sized hospitals (aOR, 0.39; 95% CI 0.26-0.58) and medium-sized hospitals (aOR, 0.67; 95% CI, 0.47-0.95), government-owned hospitals (aOR, 0.70; 95% CI, 0.57-0.86), for-profit hospitals (aOR, 0.58; 95% CI, 0.48-0.71), rural hospitals (aOR, 0.70; 95% CI, 0.55-0.89), and critical access hospitals (aOR, 0.59; 95% CI, 0.47-0.73). CONCLUSIONS:Billing for TCC among hospitalized critically ill Medicare beneficiaries increased during the pandemic but remained low as a proportion of all critical care bills. There was variability in utilization across subspecialties and lesser utilization at rural and critical access hospitals. Further studies are needed to characterize the clinical and economic consequences of this shift.

BACKGROUND:Heart failure (HF) is a complex clinical condition that often requires interhospital transfer (IHT) to ensure that patients have access to the level of expertise and care that they require. However, little is known about IHT in the HF population. Therefore, we aimed to describe the characteristics and outcomes of patients undergoing IHT as well as variation in the use of IHT across hospitals. METHODS:Patients hospitalized for HF who were transferred in from another hospital were compared with those who were not transferred in using data from the Get With The Guidelines-Heart Failure registry between January 2015 and June 2022. Hospital characteristics were obtained from the 2018 American Hospital Association Survey. Clinical data from the receiving hospital were analyzed. RESULTS:Overall, 662,575 patients across 622 hospitals were included, of which 36,375 (5.5%) arrived as IHT (median [interquartile range] proportion of IHT by hospital, 1.9% [0.17%-5.88%]). Compared with patients who were not transferred in, IHT patients were younger (median age, 70 vs 73 years) and more likely to be male (58.1% vs 52.3%), White (72.0% vs 66.2%), and have private insurance (31.2% vs 26.8%). IHT patients had lower left ventricular ejection fractions (54.1% vs 41.9% with an LVEF ≤40%), lower median blood pressure (130/74 vs 139/77 mm Hg), and a longer median length of stay (5.0 vs 4.0 days). In a multivariable regression model adjusting for variables available at time of transfer, IHT patients had higher in-hospital mortality (odds ratio [OR], 1.85; 95% confidence interval [CI] 1.76-1.95), were less likely to discharge home (OR, 0.79; 95% CI, 0.77-0.81), and were more likely to be prescribed guideline-directed therapies at hospital discharge. CONCLUSIONS:More than 1 in 20 patients hospitalized for HF at hospitals participating in the Get With The Guidelines-Heart Failure program were transferred from another hospital. Rates of IHT varied across hospitals; there were sex, racial, economic, and geographic differences. Compared with patients who were not transferred in, patients with IHT had higher mortality and longer length of stay. Further efforts to assess IHT use, care quality, and outcomes are warranted to optimize transfer decisions and to contextualize hospital outcomes measures.

Background The guiding an improved dementia experience (GUIDE) model is a nationwide payment model launched in 2024 to test monthly dementia care management payment as a tool to improve care and outcomes for Medicare fee-for-service beneficiaries with dementia and their caregivers. GUIDE requires participating practices to provide comprehensive dementia services, including care assessment and coordination, caregiver support, and respite services. This study assessed baseline billing patterns for GUIDE-required services among eligible physician group practices prior to GUIDE implementation. Methods Using 2022 Medicare clinician and practice data, we identified a national sample of eligible physician group practices for GUIDE, defined as having at least one dementia-proficient clinician. Among eligible practices, we examined the variation in their billing patterns for GUIDE-required services under the Medicare fee-for-service fee schedule. We identified and decomposed practice-level factors predictive of billing for any GUIDE services and assessed the association between these factors and service volume. Results Among 4737 eligible practices, 60% billed for GUIDE-required services; however, these services were substantially underused by dementia-proficient clinicians. Practices billing for more required services under fee-for-service were larger, more likely to participate in other risk-based payment models, such as accountable care organizations, but had smaller dementia caseload shares and served patients with lower overall clinical risks. Conclusions Before GUIDE implementation, billing for required services varied substantially across eligible practices and was underused by dementia-proficient clinicians. These baseline differences may help explain early participation patterns and inform future evaluations of whether GUIDE incentives build capacity for delivering comprehensive dementia care.

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.

Background Social drivers of health (SDOH) are major contributors to future disease. As the population ages, it is important to understand projections of cardiovascular disease (CVD) according to SDOH. Objectives The objective of the study was to determine CVD projections according to education, insurance, and income. Methods We estimated future projections of risk factors for CVD, individual CVD conditions (ie heart failure), and total CVD from 2020 to 2050 according to SDOH of the United States using the National Health and Nutrition Examination Survey, Medical Expenditure Panel Survey, and U.S. Census. Results By 2050, most risk factors and individual CVD conditions are estimated to worsen and remain the worst for those with less education, Medicare or Medicaid beneficiaries, and lower income. Counterintuitively from 2020 to 2050, total CVD prevalence is expected to incrementally increase with higher levels of education (10.0 percentage points higher for college graduates), reaching similar prevalence across education levels by 2050. Medicare beneficiaries are projected to have the highest prevalence of total CVD throughout the era, reaching 86% by 2050. Increases in total CVD prevalence are projected to be similar across income categories. Conclusions Total CVD prevalence is projected to increase from 2020 to 2050 across education, insurance, and income categories with greatest increases occurring in those with a college degree. However, multiple risk factors, most CVD conditions, and total CVD prevalence are generally projected to be highest among populations with less education, public insurance, and lower income compared to respective SDOH categories. Efforts to address SDOH should be prioritized to mitigate the forecast.

Atrial fibrillation (AF) is increasing in incidence, prevalence, and lifetime risk, and contributes to substantially greater health care costs and increased risks of stroke, heart failure, and mortality. Improving adherence to evidence-based recommendations equitably in AF is critical to advancing clinical care, patient outcomes, and public health. The writing committee developed a comprehensive set of 5 performance measures, which are appropriate for public reporting or pay-for-performance programs, and 16 quality measures, which are useful to clinicians and health care organizations for quality improvement. The writing committee selected the measures from the strongest recommendations (Class 1 or 3) in the “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.” The purpose of the writing committee’s performance measures is meant to ensure that patients with newly diagnosed AF receive a basic clinical evaluation, with an emphasis on secondary prevention for patients at all stages of AF, documenting stroke risk, and, if indicated, providing appropriate anticoagulation. AF quality measures cover a variety of topics including measuring and addressing health inequities, optimizing antiarrhythmic or anticoagulant treatment, engaging in shared decision-making for rate- versus rhythm-control strategies, and, in appropriate patients, offering catheter ablation for those with heart failure with reduced ejection fraction. The performance and quality measures are intended to advance the quality and equity of AF care across all patient populations with AF.