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The American Journal of Managed Care November 2017
Using the 4 Pillars to Increase Vaccination Among High-Risk Adults: Who Benefits?
Mary Patricia Nowalk, PhD, RD; Krissy K. Moehling, MPH; Song Zhang, MS; Jonathan M. Raviotta, MPH; Richard K. Zimmerman, MD, MPH; and Chyongchiou J. Lin, PhD
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Changes in Cardiovascular Care Provision After the Affordable Care Act
Joseph A. Ladapo, MD, PhD; and Dave A. Chokshi, MD, MSc
Validation of a Claims-Based Algorithm to Characterize Episodes of Care
Chad Ellimoottil, MD, MS; John D. Syrjamaki, MPH; Benedict Voit, MBA; Vinay Guduguntla, BS; David C. Miller, MD, MPH; and James M. Dupree, MD, MPH

Changes in Cardiovascular Care Provision After the Affordable Care Act

Joseph A. Ladapo, MD, PhD; and Dave A. Chokshi, MD, MSc
The authors evaluated whether the 2010 Affordable Care Act was associated with changes in physicians’ provision of preventive cardiovascular services.

Objectives: Physicians are gatekeepers to preventive care recommended by the US Preventive Services Task Force (USPSTF). We aimed to determine whether the Affordable Care Act (ACA) was associated with changes in physicians’ provision of preventive cardiovascular services, focusing primarily on patients with employer-sponsored health plans.

Study Design: Quasi-experimental, difference-in-differences (DID) approach.

Methods: We analyzed National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data from 2006 to 2013. Using a quasi-experimental DID approach with multivariate logistic models, we compared trends in preventive cardiovascular services delivered during physician visits among target and control populations prior to the ACA’s provisions.

Results: The ACA was associated with an increase in use of diabetes screening (3.9% in 2006-2010 [third quarter] to 7.6% in 2010 [fourth quarter]-2013; DID, +3.5 per 100 visits; 95% CI, 1.1-5.9), tobacco use screening in adults (64.4% in 2006-2010 to 74.5% in 2010-2013; DID, +11.6 per 100 visits; 95% CI, 4.8-18.3), aspirin therapy in men (11.1% in 2006-2010 to 13.5% in 2010-2013; DID, +2.9 per 100 visits; 95% CI, 1.1-4.6), and hypertension screening (73.2% in 2006-2010 to 76.4% in 2010-2013; DID, +9.9 per 100 visits; 95% CI, 2.8-16.9).

Conclusions: Provision of cardiovascular preventive care increased for some USPSTF-recommended services following enactment of the ACA, with evidence of a sex disparity in aspirin use. Other complementary policy approaches may further enhance uptake of evidence-based clinical preventive services.

Am J Manag Care. 2017;23(11):e366-e373
Takeaway Points

Provision of cardiovascular preventive care increased for some US Preventive Services Task Force (USPSTF)-recommended services following the Affordable Care Act (ACA), with evidence of a sex disparity in aspirin use. 
  • This study was the first to analyze changes in use of cardiovascular preventive care after the ACA by directly assessing physician decision making.
  • The ACA’s cost-sharing provisions are an effective way to increase uptake of clinical preventive services. 
  • Levels of service provision were still lower than those recommended by the USPSTF. 
  • Sex disparity in aspirin use underscores concerns about poorer-quality cardiovascular care in women. 
  • Other complementary policy approaches may further enhance uptake of evidence-based clinical preventive services.
Coronary heart disease (CHD) and stroke are leading causes of death in the United States,1 and physicians play a central role in treating modifiable risk factors among patients seeking clinical care. The Affordable Care Act (ACA) is designed to reduce barriers to preventive care, including preventive cardiovascular care, by eliminating marginal cost sharing on high-value screening tests identified by the US Preventive Services Task Force (USPSTF).2 The design of this particular provision of the ACA is unique, however, because it is unlike other policies and programs for cardiovascular disease (CVD) reduction that directly target the behavior of patients or healthcare providers—such as cigarette taxes, calorie postings on menus, or Medicare’s recently launched physician incentive program for preventive cardiovascular care.3,4 

The ACA’s economic incentives for USPSTF services indirectly target physicians’ provision of preventive care by reducing patients’ out-of-pocket costs. Because physicians are gatekeepers to these services, directly assessing their patterns of preventive care provision in response to the ACA is critical to informing the design of future policies for clinical prevention. For example, policy approaches to increasing the population prevalence of a preventive cardiovascular test or therapy may differ depending on whether the service is provided during 5%, 15%, or 50% of clinical visits in which a physician sees a potentially eligible patient. Data on physicians’ provision of preventive services may also be more persuasive to physicians than the population prevalence of preventive service penetration, since the former more directly reflects physicians’ decision making. 

To help inform future policies for preventive care in CVD, we used nationally representative data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) and examined physicians’ early response to the ACA. We primarily focused on physician visits for patients enrolled in private insurance plans because these plans insure the majority of the US population.


Study Design

We used a quasi-experimental, difference-in-differences (DID) approach to examine the impact of the ACA on physicians’ provision of preventive cardiovascular care. The DID approach measures changes in an outcome associated with a policy change, after accounting for secular trends in that outcome, as reflected in a control group that is not exposed to the policy change.5 In this study, physician visits with insured patients in the target population were defined according to criteria proposed by the USPSTF, and the control group was composed of physician visits with patients who were: a) insured but ineligible for the preventive service by USPSTF guidelines (eg, patients close to but not meeting an age threshold for a screening test) or b) self-pay/uninsured and eligible for the preventive service. We selected these control groups because we hypothesized that physicians’ provision of preventive cardiovascular care in these encounters would likely capture temporal trends unrelated to the ACA,6,7 and we formally tested this hypothesis by comparing trends among the target and control populations in preventive cardiovascular services prior to the ACA’s provisions (evidence of a difference in slopes would suggest a difference in trends prior to the ACA). These tests showed no significant differences among our target and control groups for any of the preventive cardiovascular services we evaluated, which supports our selection of control groups. 


We analyzed data collected in the NAMCS and NHAMCS from 2006 to 2013. The National Center for Health Statistics (NCHS) and the CDC conduct the NAMCS and NHAMCS annually on a nationally representative sample of visits to office-based physicians, hospital-based outpatient clinics, and emergency departments in the United States.8 Data are collected on patients’ symptoms, comorbidities, and demographic characteristics; physicians’ diagnoses; medications ordered or provided; and medical services provided. The NAMCS and NHAMCS intake materials allow physicians and staff to record up to 3 reasons for each visit and 3 diagnoses related to the visit, in addition to capturing several other major comorbid diagnoses (coded by NCHS staff using the International Classification of Diseases, Ninth Revision, Clinical Modification). 

Data on outpatient hospital departments and community health centers from the NHAMCS were unavailable from 2012 to 2013, but the majority of ambulatory care is performed in office-based visits and captured by the NAMCS (93% of visits during 2006-2011 occurred in the office rather than hospital outpatient departments, and 99% of office visits occurred outside of community health centers). However, we adjusted for the absence of these 2 care sites in our regression analyses and used the 2006 to 2011 ratio of total visits to nonhospital outpatient/non–community health center visits to adjust the 2012 and 2013 estimates of care provision.9 Our analyses included only preventive care visits (including screening and general exams), routine visits for chronic problems, or visits to primary care physicians (including physicians in family practice, internal medicine, and obstetrics/gynecology) or to a patient’s primary care clinic, because we viewed these visit types as reasonable opportunities for the provision of preventive cardiovascular care. 

From 2006 to 2013, the physician and hospital/outpatient clinic response rates in the NAMCS and NHAMCS ranged from 54% to 65% and 84% to 90%, respectively, and item nonresponse rates were generally 5% or less in both surveys. 

Study Population and Primary Measures

We evaluated 11 preventive cardiovascular services for adult patients (≥18 years) that received A or B ratings from the USPSTF prior to the ACA’s implementation. Our target populations were primarily defined as patients who were privately insured unless otherwise stated, although we did not exclude patients concurrently enrolled in public plans as the ACA expanded preventive cardiovascular benefits in Medicare and Medicaid. Including these public plans therefore provides a more accurate assessment of the ACA’s overall effects. In addition, we evaluated tobacco screening and cessation treatment among pregnant women enrolled in Medicaid because of the importance of this particular policy and its unique treatment in the ACA as a provision applicable to all Medicaid plans rather than only Medicaid expansion plans. We excluded physician visits by patients who had previously been diagnosed with the condition that was subject to screening (eg, visits by patients with diabetes were excluded from our analysis of glycated hemoglobin [A1C] use for diabetes screening). In our analysis of tobacco use screening, all adults were included, irrespective of their prior tobacco use. 

The preventive cardiovascular services we evaluated were: a) use of A1C to screen patients with hypertension for type 2 diabetes10; b) obesity management with counseling about diet/nutrition, exercise, or weight reduction11; c) measuring blood pressure in adults without diagnosed hypertension12; d) lipid testing among men 35 years or older or in high-risk men aged 20 to 34 years (high-risk defined by USPSTF as history of diabetes, previous CHD or atherosclerosis, family history of CVD, tobacco use, hypertension, or obesity by body mass index ≥30 kg/m2)13; e) lipid testing among women age 45 or older or high-risk women aged 20 to 44 years (high-risk defined similarly in women and men)13; f) aspirin therapy to prevent myocardial infarction in men aged 45 to 79 years14; g) aspirin therapy to prevent stroke in women aged 55 to 79 years14; h) tobacco use screening among pregnant women enrolled in Medicaid15,16; i) tobacco use screening among adults enrolled in private plans15; j) smoking cessation advice/counseling in pregnant smokers enrolled in Medicaid15,16; and k) smoking cessation advice/counseling in smokers enrolled in private plans.15

In our control groups, we examined physicians’ provision of these same preventive cardiovascular services in visits with: a) asymptomatic adults with normal blood pressure, b) self-pay/uninsured obese adults, c) self-pay/uninsured adults without diagnosed hypertension, d) low-risk men aged 20 to 34 years, e) low-risk women aged 20 to 44 years, f) men aged 30 to 44 years, g) women aged 45 to 54 years, h) nonpregnant women enrolled in Medicaid, i) self-pay/uninsured adults, j) nonpregnant female smokers enrolled in Medicaid, and k) self-pay/uninsured smokers. 

We hypothesized that these were plausible control groups because they likely captured temporal trends in physicians’ preventive cardiovascular care but would not be directly affected by the ACA during our study timeframe because patients either did not meet USPSTF guideline criteria or did not have an eligible insurance plan. To identify our control groups, we also considered their clinical similarity to patients in the target population. When possible, we used age to distinguish between the target and control populations (eg, men 45 years or older were eligible for aspirin therapy whereas men younger than this age were generally not) because selection based on age was used in prior DID evaluations of the ACA.17 When it was not appropriate to use an age cutoff (eg, A1C screening is based on presence or absence of hypertension among adults and is not age-specific; Medicaid tobacco use screening targeted pregnant women rather than nonpregnant women), we distinguished our target and control patients by the presence or absence of a relevant comorbidity or risk factor. When neither of these options were available or appropriate, we identified clinically similar patients and distinguished the target and control cohorts by whether they were enrolled in private plans (and therefore eligible for the provision) or were considered self-pay/uninsured (and therefore ineligible for the provision). Examples of this included measuring blood pressure in adults without diagnosed hypertension (applying age eligibility criteria was not appropriate, nor was using a control group composed of patients with diagnosed hypertension, since these patients have an established diagnosis and would no longer be eligible for screening). The validity of our control population selections was assessed in comparisons of time trends between target and control populations during the pre-ACA period, and there were no significant differences, a finding that supports our hypothesis.

All ACA provisions took effect on September 23, 2010, for privately insured patients, but we used a start date of October 1 due to data availability. For pregnant women in Medicaid, ACA tobacco coverage was required as of October 1, 2010. 

Other Measures

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